Illinois Gender Advocates

Advocates Club Enrollment Form

CONTACT INFORMATION

Name: _____________________________________________________________________________

Home Address: ______________________________________________________________________

City: ________________________________________ State: ____________ ZIP Code: _____________

Home Telephone: _________________________Work Telephone: ______________________________

Mobile Telephone: ________________________ E-mail Address: _______________________________

PLEASE ENROLL ME IN THE IGA ADVOCATES CLUB AT THE FOLLOWING LEVEL:

$250 ___________

$500 ___________

$1000 ___________

$2500 ___________