Member Name:____________________________________________ 

Address 1:________________________________________ 

Address 2:________________________________________ 

City:_____________________________State:____________ 

Zip/Postal Code:_______________ 

Country:_____________________ 

Phone:_________________     FAX: _________________ 

E-mail:__________________________ 

URL:____________________________ 

Occupation/Area of Interest:_______________________________________ 

Nature of Disability:_____________________________________________

Please indicate type of membership: 
   Student                                               ($5.00) 
   Full                                                    ($25.00) 
      Tax-deductible donation for:   student awards        $_________
                                                    other (                         ) $ ________
                                                    unrestricted                   $ ________
    Total enclosed  $_________

Payments must be made in U.S. dollars and drawn on a U.S. bank.