To become a member of OutPOCPAC, please complete the following:

_____ I am an LGBTTS Person of Color living in New York State and I want to become a MEMBER of OutPOCPAC. Enclosed is my contribution of $20 (fee can be waived upon request for limited income). Members may fully participate in all OutPOCPAC activities and meetings and may vote on endorsements and legislation at club meetings.

_____ I am not an LGBTTS Person of Color but I am interested in supporting OutPOCPAC and would like to become an ASSOCIATE MEMBER. Enclosed is my contribution of $20. Associate members may fully participate in all OutPOCPAC activities and meetings but may not vote on endorsements and legislation at club meetings.

Name: _______________________________________________________________________

Address: _____________________________________________________________________

Home Phone: _________________________________________________________________

Work Phone: __________________________________________________________________

Fax: _________________________________________________________________________

Email: ________________________________________________________________________

Enclosed is: $__________________________________________________________________

Check the committee(s) you are interested in joining:
__ Communications
__ Fundraising
__ Membership
__ Political Relations
__ Program

Your signature: _______________________________________________ Date: ______________

Please mail to OutPOCPAC
351 West 114th Street
Suite # 4A-4B
New York, NY 10026