Membership Application

Membership Information.

Name: _________________________________

Address: ______________________________

         ______________________________

         ______________________________

         ______________________________

Telephone: Office:(_____)_______________ Fax:(_____)_______________
Please include country & city code if outside USA

E-mail:___________________________________________________________

Degree(s):________________________________________________________

__________________________________________________________________

Professional Affiliation and Titles:______________________________

__________________________________________________________________

Certification/License:____________________________________________

Experience in Treatment of Gender Dysphoria:______________________

__________________________________________________________________

Human Sexuality Training:_________________________________________

__________________________________________________________________

Make checks payable to: HBIGDA, Inc.

Or you may pay by VISA or MasterCard by completing the following:

___ VISA ___ MasterCard

Account Number: ______________________________ Exp. Date __________

Signature: ________________________________________

Mail to: HBIDGA
1300 South 2nd Street, Ste 180
Minneapolis, MN 55454 USA

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