39 CR 103

Oxford , MS    38655                  


Contact Request Form


Iím not joining at this time, but please put me on the contact list.

[Please print your information on this form and mail it in or put the same information in an e-mail and send to the above e-mail address.]


Name _________________________________________________________________

Mailing Address ________________________________________________________

        ________________________________________ZIP+4 ___________________

Home Telephone: (______) __________________________

Work Telephone:  (______) __________________________

Fax: (______) _____________________________

E-mail: ___________________________________________________

Voting Precinct Name or No.: _________________   County: ________________


There are no membership dues for the Green Party of MS.  If possible, please send an individual donation of no more than $200 with your form.  Donations to the Green Party of MS are not tax-deductible.