PFLAG LAKE COUNTY
P.O. BOX 264
GURNEE, IL 60031
224-656-5530

APPLICATION FOR MEMBERSHIP:
MEMBERSHIP IS ANNUAL (1 YR) AND IS RENEWABLE 1 MONTH PRIOR TO EXPIRATION.

INDIVIDUAL - $35.00 ____

FAMILY - $45.00 ____

NAME: _____________________________________

ADDRESS: ________________________________________ APT.: _____________

CITY: __________________________ STATE: ________ ZIP CODE: __________

E-MAIL: _______________________________________

THANK YOU FOR YOUR MEMBERSHIP. CHECK OUT OUR WEBSITE (www.pflaglakecounty.org) FOR NEW MEMBER LISTING AND UPCOMING EVENTS.

MAKE CHECKS PAYABLE TO: PFLAG LAKE COUNTY