Name(s):  _________________________________________________________

Address:  _______________________________________________________

City / State / Zip code:  __________________________________________

Telephone (home):  ______________________________

Phone (work):  ______________________________

Cellphone:  _____________________________

Fax:  ________________________________

E-mail:  ___________________________________________________

Website:  ___________________________________________________

Other 411:  _______________________________________________

 

=======Membership=======

____ $25 - Veteran of the 1969 Stonewall Rebellion (plus    
                  annual Donation)

____ $50 - Friend of the S.R.V.A.

____ $10 - Student (elementary schol, charter school, high school or college)

=======Donor=======

____ $75 - Rainbow (special Friend of the S.R.V.A.)

======Sponsorship and/or Advertising=======

____ $100 - Bronze (includes various listings)

____ $250 - Silver (includes listings and quarter-page ads)

____ $500 - Gold (includes listings and half-page ads)

____ $1,000 - Platinum (includes listings and full-page ads)

____ $1,500 - Emerald (includes listings and full-page ads, emails, faxes and promo mailing)

____ $2,500 - Crystal (includes full-page ads, email blasts, fax factory and 2 promo mailings)

____ $5,000 - Diamond (includes full-page ads, email blasts, four  promo mailings, fax factory, U.S. direct mail, phone banks, hand-outs and listings)

____$10,000 - Double Diamond - (includes all of the above and double everything and  much more!)

Note:  All ads include an ~active~ link to the sponsor's or the advertiser's website.


 Total:  $_________
    
 Dated:  ____________________, 2026