2008-09 RIL Membership Application

PLEASE PRINT THIS FORM, FILL IT OUT, AND MAIL IT

WITH YOUR CASH OR CHECK PAYMENT.

For ONLINE Payment options including PayPal or Credit Card, use our

NEW ONLINE MEMBERSHIP APPLICATION

Date:   ___________________________________

Name: _______________________________________________

Address: _____________________________________________

City: _____________________ State: _____ Zip Code: ________

Home Phone: ________________________

Work Phone: _________________________

Fax#: _______________________________

Email: _______________________________________________

Please indicate the amount of your contribution enclosed:

$      5.00     Membership Fee (not tax deductible)

$________ Additional Contribution amount (tax deductible)

$________ Total amount of Contribution

                      _______ Cash ________ Check

Resources for Independent Living (RIL) would like to use your photograph and/or name in our promotional material (newsletter, poster-board, etc.)  Additionally, RIL would like to know if you are interested in sharing your phone number with volunteers via a phone tree. If you are in agreement, please initial the following permission statement.

I give RIL permission to publish my photograph, name, address and phone number, if so needed (Please initial below).

Please return your application and contribution made payable to:

Resources for Independent Living
351 High Street
Suite 103
Burlington NJ 08016

Current membership is valid June 1, 2008 through May 31, 2009

Thank you for your support. Please feel free to contact us at:

(609) 747-7745 Voice

(609) 747-1875 TTY

(609) 747-1870 FAX
if you should have any questions.

PLEASE PRINT THIS FORM, FILL IT OUT, AND MAIL IT

WITH YOUR CASH OR CHECK PAYMENT.

For ONLINE Payment options including PayPal or Credit Card, use our

NEW ONLINE MEMBERSHIP APPLICATION

Date Last Updated: 09/27/2011