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