Name(s): _________________________________________________________

Address: _______________________________________________________

City / State / Zipcode: __________________________________________

Telephone (home): ______________________________

Phone (work): ______________________________

Cellphone: _____________________________

Fax: ________________________________

E-mail: _______________________________________________________

Website: ___________________________________________

Other 411: _______________________________________________

 

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

____ $25 - Veteran of the 1969 Stonewall Rebellion

____ $50 - Friend of the S.V.A.

____ $10 - Student (high school or college)

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

____ $75 - Rainbow

======Sponsorship=======

____ $100 - Bronze (includes e-mailings)

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

____ $500 - Gold (includes half-page ads, faxes and e-mailings)

____ $1,000 - Platinum (includes full-page ads, emails and 1 promo mailing)

____ $1,250 - Emerald (includes full-page ads, emails and 2 promo mailings)

____ $2,500 - Crystal (includes full-page ads, emails and 3 promo mailings)

____ $5,000 - Diamond (includes full-page ads, emails and 5 promo mailings)


 Total:  $________      Dated:  _______________, 2010