Please provide the following contact information (Red lettering indicates mandatory field):

First Name
Last Name
Middle Initial
Title	(Organizations only)
Organization	(Mandatory for organizations, optional for individuals)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL	(Organizations only)

Please choose one of the following options:

INDIVIDUAL ORGANIZATION

ALL MEMBERSHIP IS FOR ONE YEAR, UNLESS OTHERWISE SPECIFIED.

Please choose one of the membership options listed:

INDIVIDUALS:

MEMBER ($10)
SUPPORTING MEMBER ($20)
ADVOCATE ($30)
LIFE MEMBER ($75)
LIFE ADVOCATE ($100)

ORGANIZATIONS:

MEMBER ORGANIZATION ($60/$100)
SUPPORTING ORGANIZATION ($75/$125)
ADVOCACY ORGANIZATION ($125/$200)
ADVOCACY PLUS ORGANIZATION ($150/$250)

The second number (following the slash) indicates reduced rate for two year membership.

Please choose one of the following options (organizations only):

ONE YEAR TWO YEARS

How did you first learn of the Disabled Riders Coalition?

DUES:

$

Please choose one of the following payment methods:

CHECK (Please see directions at bottom of page)
MONEY ORDER (Please see directions at bottom of page)
CASH (Please do NOT mail cash.  Hand deliver to authorized representative)
CREDIT/DEBIT CARD OR ELECTRONIC CHECK VIA PayPal (INDIVIDUALS  | ORGANIZATIONS)

        If paying by check or money order, please choose one of the following options:

MAIL

COMMENTS, QUESTIONS OR CONCERNS:

If paying by check or money order, please make payable to "Disabled Riders Coalition" and mail to:

Disabled Riders Coalition

1204 Avenue U

Suite 1055

Brooklyn, New York 11229