Application Form

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Application Form

Membership Application

Email *

Type of Membership *

New

Renewal

Required

First Name *

Middle Int.

Last Name *

Street Address *

City *

State *

Zip Code *

Date of Birth (we ask this to verify voter registration) *

YYYY

Telephone Number *

Are you a registered voter? *

Yes

Required

What is your political party? *

Are you a member of any other political organization? *

List other community affiliations

Are you interested in serving as a poll worker during elections? *

Yes

Required

If yes, are you currently serving as a poll worker? *

Yes

Required

Are you currently a full-time student? *

Yes

Required

How did you hear about Shirley Chisholm Democratic Club? *

Select a Committee(s) to Participate in (no more than two) *

Civic Engagement

Fundraising

Membership

Programming

Public Policy

Required

ACKNOWLEDGMENT: I acknowledge that the above is true and that, if my application is accepted, I will serve as a member of the Shirley Chisholm Democratic Club ("SCDC") and contribute toward the organization of this organization. I will abide by the guidelines set forth by SCDC. Please type in your name and the date. *

SCDC's fiscal year is a calendar year, from January through December. The membership year is based on an anniversary year. Payment for renewal of membership is due prior to the beginning of each anniversary year. Submission of all payments must be accompanied by an application. Failure to pay membership dues timely will result in cancellation of membership.

Please select your level of membership *

General Membership ($25.00/year)

Senior membership ($10.00/year) (Applicant must be age 62 and over. Proof may be required for new applicants)

Student membership ($10.00/year) ($10.00/year) (Applicant must be a student at an accredited school. Proof may be required.

Checks or money orders should be made payable to the Shirley Chisholm Democratic Club and can be sent to Shirley Chisholm Democratic Club, P.O. Box 100363, Brooklyn, NY 11210. Credit card payments may also be accepted via the website.

For questions or to obtain additional information about SCDC you many contact us at scdcbkny@gmail.com and someone will get back to you. We thank you for your interest in the Shirley Chisholm Democratic Club.

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