Membership             

      Application

                                      

Gender

Name you Prefer __________________________________

Mailing Name (if Different) ________________________________

(Voluntary Entry) but should be

given in case of an emergency

Address ______________________________________________

City __________________________________________________

State _________________________________________________

Zip __________________________________________________

E-Mail Address _________________________________________

Telephone Number (Area Code First) (                ) _______________

Who should we ask for when calling? _______________________

Chapter Membership Fee:  1 Year Membership $30.00 $_________

Payment Method:  

   You can opt to make Payments at meetings of $5.00 increments until you reach the total membership fee

then stop making payments. You can continue to make donations at meetings of $5.00 if you like. Your first

$5.00 payment will grant you membership in ROSE but you must continue to make $5.00 payments at each

meeting until the fee is paid in full. The Fee must be paid in full within 10 months of beginning your

memberships first installment..

                                                                     

                                                                     

                               

                                                              

                                                                         

                                                                            

                                                                            

                                                                              Signature: ______________________________________________

                                                                         Date: _________________________________________________                                                                                  

                                                                            Credit card Payment can only be accepted if paying the

                                                                             yearly Membership Fee in full or for Donations          

                                                                                                                                                                                                   Thank you for supporting Renaissance and becoming a Member

Renaissance of

South Eastern Pennsylvania

Renaissance of South Eastern Pennsylvania

PO Box # 1322,

York, Pa ... 17405

Michelle Lynn GreyFeather .. Phone: # 717-413-1245

Ellen Davidson ........................Phone: # 717-332-1247

Members ID Number:

Effective Date:

Expiration Date:

    Rejected:*             Joined:*

Comments:

Privacy Policy:

Any Information you give to REN SEP in this Application will be held in the strict Privacy only available to the President, Vice President & Secretary / Treasurer of the REN SEP Chapter.

How did you find out about us?

It will help us reach others

   

    Internet

    Renaissanceational Referral

    Renaissance Member

    Other

Renaissance Transgender Association, Inc.  .......  Revised April, 2009

Consider an additional donation to:

Renaissance SEP ..........................$ _________

Renaissance National ...................$ _________

Total Amount Due ..........................$ _________

      Cash

      Check (Make payable to Renaissance LSV)

      Visa*                   Master Card*

Card Number:

Expiration Date: (mm) (yy).

Name on Credit Card: _____________________________________