GREEN PARTY OF MISSISSIPPI

8 Gumtree Drive

Oxford , MS    38655

greenpartyms@hotmail.com                            www.greenpartyms.org

Contact Request Form

I’m 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.