Name:_____________________________________________ 

Address:__________________________________________ 

City, State, Zip:_________________________________ 

Closest Metro Area to you :_______________________ 

Phone:______________ 

Email (print clearly)____________________ 




How did you find out about SAFE? 

O Internet search 

O News media article or broadcast 

O Professional referral 

O A friend 

O Other_________________________________________________ 




I want to help support the work of Stop Abuse For Everyone. 

___ Enclosed is my check for US$20.00 in annual membership dues

__________________________________Signed, Date:_______________

Please mail to SAFE, 16869 SW 65th Ave PMB 212, Lake Oswego, OR 97035