Application for membership into the
C.F.P.A.
P.O. Box 1106
Newton, N.C. 28658
www.falangist.com

Name: ___________________________________________________________

Address: _________________________________________________________

City _____________________________________________________________

Zip ________________ E-mail address: ________________________________

Phone: ___________________ Occupation: _____________________________

Birth Date: Month______ Day______ Year______

Education: Grade School(_) High School(_) College(_) Some College(_) Other(_)

I here by swear that I _____________________________ am not a Leftist, Racist,

Moslem nor a Mason and that I will abide by the rules and aims of the

Christian Falangist Party of America and that the above information is true, so help me God.

Sworn to and subscribed before me this ______ day of _________________, 20_____

___________________________
Notary Public

(Official Seal)

My Commission Expires___________________, 20____