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 5-5-2015