Membership Form
___ Please contact me for volunteer opportunities
___ New ___ Renewal ___ Change of address
Name:______________________________________________
Address:____________________________________________
City:___________________________State:________________
Zip:___________________Phone:________________________
___Enclosed is my check payable to PFLAG/Suburban Chicago
___Please make a one time charge to my credit card.
___Please make a $______charge to my credit card ___Monthly
___Quarterly ___Semi-annually Charges will appear as PFLAG
Card Type: ___American Express ___Visa/Mastercard
Card #___________________________________________________
Signature:_________________________________________________
___ Contributing Membership $100.00
___ Supporting Membership 50.00
___ Household Membership 35.00
___ Individual Membership 25.00
___ Student/Limited Income 15.00
___ Donation _______
Donations are tax-deductible to the fullest extent allowed by law. All names are confidential. On occasion, information from other approved
organizations is sent to PFLAG members. If you prefer not to receive these mailings, please check here ___.
Please print out the form above and send to: PFLAG/Suburban Chicago, P.O. Box 105, Downers Grove, IL 60516
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