Membership Application Form

Please fill out the Membership Application Form and mail it to PO Box 1564 Bakersfield, CA 93302

Please Signup
*
Are you registered to vote as a Republican?
YesNoNot Sure
Please check at least one option.
Please enter valid data.
*If you are unsure of your voter status, go to https://voterstatus.sos.ca.gov/
*
Username
Username can not be left blank
Please enter valid data.
This username is already registered, please choose another one.
This username is invalid. Please enter a valid username.
*
First Name
First Name can not be left blank.
Please enter valid data.
This first name is invalid. Please enter a valid first name.
*
Last Name
Last Name can not be left blank.
Please enter valid data.
This last name is invalid. Please enter a valid last name.
*
Email Address
Email Address can not be left blank.
Please enter valid email address.
Please enter valid email address.
This email is already registered, please choose another one.
Cell Phone
Text field can not be left blank.
Please enter valid data.
*
Password
Password can not be left blank.
Please enter valid data.
Please enter at least 6 characters.
    Strength: Very Weak
    *
    Select your District Supervisor
    Philip Peters- District 1Zack Scrivner - District 2Mike Maggard - District 3David Couch - District 4Leticia Perez - District 5
    Please select only one option.
    Please enter valid data.
    If you do not know your District Supervisor go to https://www.kerncounty.com/bos/YourSupervisor/
    *
    Address
    Text field can not be left blank.
    Please enter valid data.
    *
    City
    Text field can not be left blank.
    Please enter valid data.
    *
    State
    Text field can not be left blank.
    Please enter valid data.
    *
    Zip Code
    Text field can not be left blank.
    Please enter valid detail.
    Please enter valid detail.
    *
    Birthday
    Please select date.
    Invalid Date.
    Anniversary
    Please select date.
    Invalid Date.
    New MembershipMembership Renewal
    Please select one option.
    Please enter valid data.
    *
    Please indicate area(s) in which you have an interest or experience
    Campaign ActivitiesCaring for AmericaCommunity Outreach / ServiceFundraisingHospitalityLegislationLiteracyMembership PromotionPublicity / MediaSocial MediaSupporting our TroopsI can help wherever I am neededI cannot help in any of these areas
    Please check atleast one option.
    Please enter valid data.
    Special Talents (graphic design, database, editing, writing, campaigning, website management, etc.)
    This Field can not be left blank.
    Please enter valid data.
    Please tell us about any issues that concern you that you would like to get involved with:
    This Field can not be left blank.
    Please enter valid data.
    Submit