The New York Association for Gender Rights Advocacy
Membership Application Form

This information is kept confidential. Members will receive our newsletter and ongoing announcements via e-mail regarding NYAGRA's activities.  You do not have to reside in the state of New York to join NYAGRA.

INSTRUCTIONS: 1. fill in blanks, 2. then print form, 3. sign in ink or include check,
4. Mail to:  NYAGRA, 24 W. 25th St, 9th floor, New York, NY 10010

contact name
membership card name
telephone #
street Address


e-mail address @
gender identity (optional) sexual orientation (optional)
age (optional)  race/ethnicity (optional) 
check box if all contact from NYAGRA should be discreet

membership options (please check one):
$20 basic annual membership
$10 annual membership (students, senior citizens, limited income)
I want to be a NYAGRA member but need a fee waiver
I want to make an additional tax-deductible contribution of $
payment method: (please check one):
enclosed is my check or money order made payable to NYAGRA
please charge my credit card:   VISA  MasterCard  American Express
CARD NUMBER EXP DATE
SIGNATURE______________________________________
NAME (print)______________________________________today’s date