New Member Application
Date:   Sex: Male    Female
Prefix: Mr. Mrs. Ms. Miss
First Name: MI  Last Name 
Suffix (Jr, III): NickName   Birthday
Spouse's Name: Anniversary 
Home Address:
City:   State:   Zip:
Occupation:
Employer:
Business Address:
City: State:   Zip:
Home Phone: Fax Number:
Business Phone: Preferred Mailing Address:  Home  Business
E-Mail Address: (required)
Sponsor's Name:
To be completed by the club secretary
Chapter:   Chapter Number: 
Type of activity: new member   reinstated member
transfer from: (chapter)
Sponsor's ID no.: Sponsor's Chapter:
(If this is a dual membership, there will be no sponsor)
Name of secretary:
Are you interested in helping AMBUCS create opportunities and independence for people with disabilities, but cannot be an active club member? Fill in this form, check the box below, and mail AMBUCS Resource Center, PO Box 5127, High Point, NC 27262 your annual tax-deductible donation of $25. We'll send you the AMBUCS quarterly magazine and periodic reports.

Yes, I want to become a Friend of AMBUCS

Comments:

AMBUCS Resource Center

PO Box 5127
High Point, NC 27262
Phone 336-869-2166
fax 336-887-8451

World Wide Web Site http://ambucs.com

[email protected]
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