Affirmation Contribution Form

I would like to help in the support of Affirmation as follows:

  • Monthly contribution of $_______

    By Check_____ By Credit Card_____

  • One time contribution of $_______

    By Check_____ By Credit Card_____

____ Earmark this donation toward the following purpose:

__________________________________________________________________________________


Name _______________________ Telephone ______________ (optional)

Address ______________________________________________________

City, State, ZIP _______________________________________________

E-mail ___________________________________ (optional)

Chapter __________________________________________

Payment Method: Check_____ Mastercard_____ Visa_____

Amount $__________________

Card Number: __________________________ Expiration Date: ________

Authorizing Signature ___________________________________________

May we acknowledge your contribution in the National Conference program or Affinity? Yes_____ No_____

First name and last initial only please_____

Other (explain)________________________________________________

Please send contributions to:

Affirmation
PO Box 6369
Long Beach, CA 90806

Or call or send e-mail for more information to Mike Miner, our National Treasurer:

treasury583affirmation.org
562 426-5158

© 1996-2001 Affirmation: Gay & Lesbian Mormons. All rights reserved.