NORTHWEST
Gender Alliance
Application Form
Member Application Form,
Return this form WITH payment to:
NWGA, PO Box 4928, Portland OR 97208
OR deliver in person to an event.
All information is kept confidential.
Please type or print clearly:
TG Name____________________________Date____________
Membership Type: □ Regular □ Honorary* □ Scholarship □ New
Annual dues are $40
(or $45 if you elect to have a hard copy of the newsletter mailed to you.)
Would you like a hard copy mailed to you? □ No □ Yes
Would you like confirmation of payment? □ No □ Yes
Mailing Information:
Legal Name_________________________________________________ Address________________________________________Apt#________
City____________________________State_____Zip Code_________
Other Information (optional):
Date of Birth_______________________
Phone #________________________Ask For?_____________
E-mail Address________________________________________
Preferred method of contact: □ Mail □ Phone □ E-mail
Revised 10-11-10
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