Membership Application Form


Please print the following, complete and return to the address listed at the bottom of this page.

 Name:

Address:

City, State

Zip code:

Country:

Phone:

Fax:

 E-mail or Web Site Address:

Occupation:

Reasons for wanting to join COYOTE LA:

I hereby certify that I am not a police officer or undercover agent of any law enforcement department or agency seeking to join for the purpose of identifying sex workers or to gather information on or about sex workers for the purpose of arrest and/or prosecution under the laws of any federal, state or local governmental or regulatory body or agency.
 
 
Signature:

Completely fill out and mail, with your check, to: COYOTE Los Angeles, 1626 N. Wilcox #580, Hollywood, CA 90028