Date________________

Name__________________________________________________

Address_________________________________________________

City____________________ State_________________Zip________

Phone: (Home)_____________________(Work)__________________

(    ) $10 Individual (    ) $15 Family (    ) $35 Business
(    ) $5 Staff/Student (    ) $2 Customer

(    )New Membership (    )Renewal (    )Membership plus contribution

Please print and mail to
The Arc of Tuscaloosa County
PO Box 40246
Tuscaloosa, AL 35406