TBLC of Virginia Leather Club

   Membership Application

**membership is open to all persons of legal age who support the organizational purpose **

 *PRINT PLEASE*

FULL NAME_______________________________

ADDRESS__________________________________

CITY______________________________________

STATE_____________________________________

ZIP CODE_________________________________

EMAIL ADDRESS__________________________

PHONE NUMBER__________________________

I agree to a pledge period of three (3) months for full membership. I agree with the goals of TBLC and I certify that I am at least twenty-one (21) years old.

 SIGNATURE________________________________________

FULL MEMBERSHIP FEE $25

MONTHLY DUES $5

ASSOCIATE MEMBERSHIP $12.50/YR.

**ALL FEES ARE NON-REFUNDABLE

SEND APPLICATION TO:   TBLC OF VIRGINIA

                                            4592 LONE PINE RD.

                                            BURKEVILLE, VA. 23922

  *ORGANIZATIONAL PURPOSE*

* TO ESTABLISH AND MAINTAIN AN ORGANIZATION FOR THOSE OF THE LEATHER/ BDSM COMMUNITY

* TO PROVIDE SUPPORT TO AND DEVELOP COMMUNICATION AND UNDERSTANDING WITHIN THE LEATHER COMMUNITY

* TO SUPPORT PROGRAMS BENEFITING THE LEATHER/ BDSM COMMUNITY

* TO DEVELOP AND MAINTAIN A COMMUNICATION NETWORK WITH SIMILAR ORGANIZATIONS

CONFIDENTIALITY

**MEMBERSHIP LISTS ARE MAINTAINED CONFIDENTIAL WITHIN TBLC OF VIRGINIA**