Membership Application ZAMI NOBLA is a 501 (c) (3) tax-exempt, national organization for Black Lesbians over 40. We promote conscious aging and challenge ageism. We fight actively against other oppressions including homophobia, racism, sexism, ableism, classism, and transphobia. We use education, advocacy, the arts, social networking, community programming, and community based research as connecting points. This is a confidential form. Please fill out all fields and print as clearly as possible.First Name:* First Last Name* Last Are you a black lesbian?*YesNoAddress: Street Address Street Address: Address Line 2 City: City State or Province: State / Province / Region Zip or Postal Code: ZIP / Postal Code Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* Do you have a Disability that requires accommodation or accessibility?Home PhoneCell PhoneEmail What is the best way to contact you? Home Phone Cell Phone Email When is the best time to contact you? Morning Afternoon Evening How did you hear about ZAMI NOBLA?ZAMI NOBLA wants members to be as involved as possible. Please select your areas of interest. Your participation is encouraged and appreciated. Mentoring Group Facilitation Community Outreach Speakers Bureau Event Volunteer Event Planning Fundraising Publicity Marketing Newsletter Assistance Social Media Assistance Web Design Graphic Design Please list any skills or talents that you can contribute to ZAMI NOBLA:What would you like to see ZAMI NOBLA Do?What other organizations are you a member of?Please considering making an optional donation as a membership fee. A minimum of $50.00 will entitle you to: Membership Card Quarterly Newsletter Discount at Selected ZAMI NOBLA Paid Events ZAMI NOBLA Members “Only” Appreciation Events Donations by check can be mailed to: ZAMI NOBLA, Inc. P.O. Box 90986 Atlanta, GA 30364 Donations can also be made by Paypal.