DATE:___/___/___

TYPE: __ State Chapter Name of state:___________________

          __ Local Chapter Name of locality: _________________

1.) Chairman’s Name: ___________________________

      Address: ________________________________

     City, State, Zip: ___________________________

Day Phone: (____) ___-______ Night Phone: (____) ____-_____

Fax: (____) ___-______ eMail: __________@____________.____

2.) Treasurer’s Name: ___________________________

     Address: ________________________________

    City, State, Zip: ___________________________

Day Phone: (____) ___-______ Night Phone: (____) ____-_____

Fax: (____) ___-______ eMail: __________@____________.____

3.) Secretary’s Name: ___________________________

     Address: ________________________________

     City, State, Zip: ___________________________

Day Phone: (____) ___-______ Night Phone: (____) ____-_____

Fax: (____) ___-______ eMail: __________@____________.____

Names of additional Chartering Members:

4.) ____________________________________________

5.) ____________________________________________

6.) ____________________________________________

7.) ____________________________________________

8.) ____________________________________________

9.) ____________________________________________

10.) ____________________________________________

Others: _________________________________________

             _________________________________________

Briefly respond to the following questions. Feel free to use additional paper if necessary:

A.) What do you intend to be the membership and/or dues requirements for your chapter?

_____________________________________________________

_____________________________________________________

B.) When will elections be held and by what means (convention, mail, Internet, etc.)?

_____________________________________________________

_____________________________________________________

C.) Why do you want to start a Republican Liberty Caucus chapter in your state and what do you hope to what accomplish?

_____________________________________________________

_____________________________________________________

D.) What experience or background do the petitioners bring that will enhance the chapters chance for success?

_____________________________________________________

_____________________________________________________

E.) What are your plans for funding your activities?

_____________________________________________________

_____________________________________________________

Please attach any additional supporting documentation to this application and mail to:

State Charter Application
Republican Liberty Caucus
Douglas Lorenz
9380 Linda Rio Drive
Sacramento, CA 95827

Your application will be reviewed by our state chapter liaison, David Kamioner, who may be back in touch with you for additional information before forwarding your application to the RLC National Committee for discussion and possible approval.

If you have any questions or need assistance preparing your application, feel free to contact: Doug Lorenz at (916) 213-0543 or Doug@Lorenz.net

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