Individual membership application

*  indicates a required field

Contact information

*  Name  

*  Home address  

*  City    *  State   *  Zip Code  

Home phone -- 

Cell phone -- 

Business phone -- 

Home e-mail  

Other e-mail  

Membership information

Type of membership for which you are applying:

•   Full individual membership (you must have attended an Arizona Town Hall in the past)
•   Associate individual membership

Please note: Membership requires annual dues of $100. Complete the Member Dues Form and mail your payment, as online processing currently is not available.

Have you attended a Town Hall meeting?

•  Yes
•  No

If 'yes,' which one? (enter date and/or topic)
 

Tell us about yourself

In 500 words or less, please tell us what community activites you have been involved in, what positions you have held or what you think qualifies you to participate in the Arizona Town Hall.