GREEN PARTY OF MISSISSIPPI
8 Gumtree Drive
Oxford, MS 38655
greenpartyms@hotmail.com                                    www.greenpartyms.org

Membership Form
[please print]

Name _________________________________________________________

Mailing Address ________________________________________________

_______________________________________ZIP+4 __________________

Home Telephone: (______) __________________________

Work Telephone: (______) __________________________

Fax: (______) _____________________________

E-mail: ______________________________________________________

Voting Precinct Name or No.: _________________ County : ________________

I support the Green Party of Mississippi and its purposes to work for peace, grassroots democracy, social and economic justice, and an ecologically sustainable society. I am in general agreement with the Ten Key Values of the Green Party of Mississippi: Ecological Wisdom, Social Justice, Grassroots Democracy, Nonviolence, Decentralization, Community-Based Economics, Feminist Values, Respect for Diversity, Personal and Global Responsibility, and Future Focus.

Signature: ________________________________ Date: _________________

Svr Dist ___, CD ___, Sen Dist ____, Hse Dist _____, SCt Dist ___, Municipal Ward ___

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