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.

ORGANIZATION - $100.00      ____

BUSINESS - $200.00               ____ (Your business logo will appear on our website as a supporting member)

ORGANIZATION/BUSINESS NAME:  _____________________________________

CONTACT NAME:  _____________________________________

ADDRESS:  ________________________________________

CITY:  __________________________    STATE:  ________   ZIP CODE:  __________

PHONE NUMBER:  _________________

E-MAIL:  _______________________________________

THANK YOU FOR YOUR MEMBERSHIP AND CONTINUED EFFORTS IN HELPING SUPPORT OUR FAMILY AND MAKING PEOPLE AWARE.  CHECK OUT OUR WEBSITE (www.pflaglakecounty.org) FOR NEW MEMBER LISTING AND UPCOMING EVENTS.

MAKE CHECKS PAYABLE TO:  PFLAG LAKE COUNTY