Become a member of the
 

Check one:

____	1 Year individual membershipwith membership in National Stonewall ($34)
____	1 Year household membership with 2 memberships in National Stonewall ($56)
____	1 Year individual membership ($24)
____	1 Year household membership ($36)

Name (s):  ___________________________________________________

Address:   ________________________________

                ________________________________
               
                ________________________________

E-mail:      ________________________________

Home Phone:    ____________________________

Work Phone:    ____________________________

Please print, fill out and return this form with your check to:

Stonewall Democratic Club of New York City
PO Box 514
Old Chelsea Station
New York, NY 10113