THE ARC OF INDIANA
MEMBERSHIP FORM

Yes, I want to support the work of The Arc of Indiana

Please check the type of membership:

    _____ Individual Membership                                                           Dues $15
    _____ Family Membership                                                                Dues $25
    _____ Self-Advocate Membership (person with a disability)       Dues $ 3
    _____ Professional/Corporate/Organizational Membership        Dues $100

Please print and mail this form, along with a check, made payable to The Arc of Indiana;
or you may charge your membership to a credit card. 
Mail to:  The Arc of Indiana, 107 N. Pennsylvania St., Suite 300, Indianapolis, IN 46204

___  Check Enclosed    ___ Visa    ____ MasterCard

Card Number:_______________________________________    Expiration Date: _______
CID # (on back of card) __________

Signature:_______________________________________________________

NAME:________________________________________________________

ADDRESS:_____________________________________________________

CITY:___________________________ STATE:_________ZIP:__________

PHONE NUMBER:______________________________________________

E-MAIL:_______________________________________________________