Please Print & Fill this form and mail it along with your check to

Manhattan Libertarian Party

c/o Mark Axinn

175 E. 73rd St

New York , NY 10021

Name ____________________________________________________

Address __________________________________________________

City _______________________________ State ____ Zip __________

Home Phone __________________ Work Phone __________________

E-mail address _____________________________________________

LP Member # (if known) ________________________ ( National & State )

Please make Checks payable to "Manhattan Libertarian Party" for $15 and send to the address above .

• To pay by Credit Card , please use our online facility at http://www.manhattanlp.org/join.htm .

* Annual Dues are for memberships that generally expire on January 1 each year (see bylaws) and are not automatically renewed.

* Political contributions are not tax deductible