Membership page - NLA International

Individual Membership

New Member
N/A- select other option

Commercial Membership

New Commercial Member
N/A - select other

Affiliate Membership

New Affiliate Membership
N/A select other

Company name:

Last Name:

First Name:

Middle Initial

Scene name or name on card desired:

Name Used On Postal Mail if different:

Street / P.O. Box Address

City

State / Province:

Zip

Postal Mail Allowed?:

Yes
No

Phone Number:

Alt Phone:

E-Mail:

PayPal E-Mail Address if different (You must use paypal after you submit this application)

If you are signing up as a Commercial/Affiliate Membership and you want us to list your company or group, please porvide us a website:

Please select member type or chapter:

Name of Club in formation:

Name of Event Org in formation:

Select Individual Member Dues:

Annual Renewal $25.00 USD
N/A

Select Commercial Member Dues:

Annual Renewal $90 USD
Discount offering renewal $75 USD
N/A

Affiliate Member Dues:

Annual Renewal $90 USD
Discount Offering Renewal $75 USD
N/A

Optional Demographic information:

Optional Gender Information:

Optional Orientation:

Select, if you have chosen to make an additional donation. You will need to add the donation amount to your Paypal balance upon checkout.

Domestic Violence Project (tax deductable)
Living In Leather Project (tax deductable)
NLA Operating Funds (non-tax deductable)

Agreement

I attest by my typed signature contained in this form that I am at least 18 years of age and of legal age of majority in my state or province of residence. By selecting "SEND," I acknowledge that I have read the NLA-I Statement of Purpose. I agree with the goals of NLA-I and wish to support its efforts of activism, concern, education, and public service. I understand that information on this form will be handled according to the confidentiality rules set forth in the Bylaws. I agree as a member to follow the Bylaws of the Association.
I agree

Typed Signature (real name):

Date mm/dd/yyyy: