Standard Membership (Household) Application

Thank you for supporting the Florida LGBTA Democratic Caucus. To complete your new membership or renewal application, please answer the following questions and click the SUBMIT button.

After you submit your application, you will be re-directed to the PayPal website to process your household membership dues payment of $50.

* indicates required field

First Name:*

Last Name:*

2nd Member's Name:*

Email:*

Re-enter Email:*

2nd Member's Email:

Date of Birth:*

Street Address:*

(Include apartment or suite number if necessary.)

City:*

State:*

(Use two-letter abbreviation.)

Zip Code:*

Telephone Number:*

County of Voter Registration:*

Are you a local DEC member or elected official?*

Yes
No

If you answered yes to the previous question, please provide title of office held:

Gender:

(For statistical reporting purposes.)

2nd Member's Gender:

(For statistical reporting purposes.)

Race:

(For statistical reporting purposes.)

2nd Member's Race:

(For statistical reporting purposes.)

Membership Status:*

New Member
Renewal

Membership Type:*

Voting Member
Associate Member