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Membership Form 2011/12 Name: .......................................................................................................... Address: ......................................................................................................
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I am not a citizen of any state or country. Date of Birth: (mm-dd-yyyy) Place of Birth: (mm-dd-yyyy) Country where you are? I am not a permanent resident. (Yes or No) Which part of Pennsylvania? United States or Canada I understand that for Federal purposes the mailing of the membership list to each local political party, organization, political action committee (PAC) and political action committee (PAC) candidate is required by law on the 30th of the month following the election in which you are a candidate. Please reply with the name of each candidate and the address where they live. (Yes or No) (No, I am an attorney) If the list will be used for any other purpose or if it is kept by us, I authorize you to use it for that purpose. (Yes) If you are not a UNITED STATES CITIZEN, you must attest that for the purpose of my membership you are authorized to collect dues and fees. (I agree) The information on the form is the same for a member of the United States Congress, U.S. Senate, State General Assembly, County or City Commission in Pennsylvania, Town or Village Commission in Pennsylvania, Town Meeting in Pennsylvania. If the information is being furnished for a political party, organization, PAC or PAC candidate, then the form is for that purpose and may not be used with reference to the membership for another political party, organization, PAC or PAC candidate. (Yes or No) (No, I am an attorney) I agree that All the information provided on this form is true and accurate. If applicable, I also agree that I understand that by submitting this form under penalty of perjury, I am asserting that I am a UNITED STATES CITIZEN. If (and only if) the information on this form and the form enclosed with this membership application is true and accurate under penalty of perjury, I hereby authorize the following to occur on my behalf: (I authorize all the following to occur on my behalf) The collection of my membership dues and fees by the United States House of Representatives and United States Senate. The collection of my registration information, if there is one, from any town, city or county body. The use of the information contained in this form by the United States House of Representatives and the United States House of Representatives committees that control legislative elections.

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Membership form 12 is a document used to register or update membership information for a specific organization or group.
Any individual who wishes to become a member of the organization or group must file membership form 12.
To fill out membership form 12, you need to provide personal information such as your full name, contact details, and any additional information requested by the organization.
The purpose of membership form 12 is to collect and maintain accurate information about the members of an organization or group for administrative purposes.
Membership form 12 typically requires information such as full name, address, contact details, date of birth, occupation, and any other relevant information as specified by the organization.
The deadline to file membership form 12 in 2023 will be determined by the organization or group. It is best to contact them directly for the specific deadline.
The penalty for the late filing of membership form 12 can vary depending on the organization or group's policies. It is advised to consult their rules and regulations to determine the applicable penalty.
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