Yes, I'll join the Libertarian Party (Check one)
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| York County LP only (Not a State or National Member)                      [  ] $25 |
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| York County LP only (Currently State & National Member)                   [  ] $15 |
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| Combo Membership (National, State with mailed newsletter & York County)   [  ] $40 |
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(Membership fees shown are due only once a year!)

[  ] Membership payment made by credit card at the Libertarian Party's eCommerce site
     on (specify date) ____/____/______.

New members please sign:
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| I hereby certify I do not believe in, or advocate, the initiation of force to      |
| achieve social or political goals.                                                 |
|                                                                                    |
| Signature: _________________________________________________                       |
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| Date: ____/____/______                                                             |
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| I want to make York County a community of Libertarians!                            |
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| Here is my gift of [  ] $100  [  ] $75  [  ] $50  [  ] $25  [  ] Other $__________ |
| to help spread the word.                                                           |
|                                                                                    |
| Name: _______________________________________________________________              |
|                                                                                    |
| Street: _______________________________________________ Apt: ________              |
|                                                                                    |
| City: ____________________________ State: PA  Zip Code: _____________              |
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| County: York                                                                       |
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| Home Phone: (_____)_______________  Work Phone: (_____)______________              |
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| FAX: (_____)________________                                                       |
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| E-mail:________________________________________                                    |
|                                                                                    |
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Please send this membership form and contributions to:
Libertarian Party of York County, 1931 Carlisle Rd, York PA 17408.