Fifty/Fifty Leadership

Fifty/Fifty Leadership
Membership Application
(Please print this application)

PLEASE PRINT
Yes! I accept your invitation to become a Member of Fifty/Fifty Leadership. As a Member I will receive all the benefits listed!

Name: _________________________________________________________________________

Address: _______________________________________________________________________

City/State/Zip____________________________________________________________________

Phone: Day ( )________________________________ Eve ( ) ______________________________

Email: ______________________________@__________________________________________

To help empower women's equal leadership, I have enclosed my tax-deductible gift for:

___ $25 Student	___ $50 Member	___ $100 Friend	___ $250 Benefactor
___ $500 Sponsor*	___ $1,000 Patron*	___ Other $ ____

*With a gift of $500, $1,000 or more, you'll be invited into Fifty/Fifty's Leaders Circle, with all its exclusive benefits and privileges.

Make check payable to: Fifty/Fifty Leadership

___ I wish to charge my tax-deductible contribution to:

MasterCard

Visa

American Express

Discover

(Circle One)

Credit Card No. ______________________________________ 3 or 4 Digit Code _________

Expiration Date: Mo.______ Year ______ Amount: $_____________

Signature:_____________________________________________

Please mail your contribution along with this application to:

Fifty/Fifty Leadership, P.O. Box 11202, Glendale, CA 91226

Or fax to (818) 243-2601

Your contribution is tax-deductible in accordance with the law. Thank you for your strong support!

Fifty/Fifty Leadership was incorporated in Las Vegas, Nevada in 1996. The phone number is
(818) 243-2322. We have a 501(c)3 classification from the Internal Revenue Service.