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LGBT Membership Application This application is for an individual ($60) a business ($95) (See Below) Would you like to be listed in the directory? Yes No Contact Information Directory Information ** Company: Company: Name: Name: Title: Title: Address: Address: City: City: State: State: Zipcode: Zipcode: Home Telephone: Home Telephone: Work Telephone: Work Telephone: Fax: Fax: Email: Email: URL: http:// URL: http:// 1. Individual Membership Invitations to all events Free admission to networking social events for you ($10 admission fee for your guests) Take a Break, our bi-monthly newsletter Listing in our Membership Directory along with your very own copy 1. Business Membership Invitations to all events Free admission to networking social events for you ($10 admission fee for your guests) Take a Break, our bi-monthly newsletter Listing in our Membership Directory along with your very own copy Listing your Business name in our ads in community LGBT publications throughout the year ** (Only fill in Directory Information where different from contact)