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Today's Date: _______________________________________________
First Name: ____________________________________
Middle Name: _______________________________
Last Name: __________________________________
Street address: ______________________________________________________________________________________________________________
City: _____________________________________State: _______ Zip code: _____________ - ____________
County:________________________________
E-mail: _______________________________________________________________
Contact phone number: _______ - _______ - ___________ Type: Home Office Cellular
If needed, extension #______________________
Date of Birth: (month) __________ (day) __________ (year) _______________
Do you belong to any other political groups? _________
If "Yes" than please list them and their websites (if known): ____________________________________________
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___________________________________________________________________________________________________________________________________
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Are you a union member? ________ If "Yes" than please name: ___________________________________________
___________________________________________________________________________________________________________________________________
Are there any special concerns that you'ld like to focus on or which brought you to the YSD/YSPL:
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
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"Desiring to bring about, by democratic means, a social democratic/democratic socialist society in which all exploitation has been eliminated, I hereby apply for membership in the Young Social Democrats (Young Peoples' Socialist League). I agree to abide by its principles and platforms. I am not a member of a centralist party or tendency."
Signature: ___________________________________________________________
Print this off and send it to:
P.O. Box 5307
Johnstown, PA 15904
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