Membership Form

A Florida Not-For-Profit 501(c)3 Corporation
19333 West Country Club Drive #1522

Aventura, Florida 33180
Tel. 305 705-0059 Fax 305-792-2665
E-mail: info@adaaccessnow.org

(Please fill out all fields)

Date:	09/05/2008 11:02 am
First Name:
Last Name:
Address1:
Address2:
City:
State:
Zip:
Phone:
Fax:
Email:	(Strongly Encouraged, Very Helpful For All.)
DISABLED NON-DISABLED
If Disabled, give brief description: (mobility, wheelchair-user, part time/full time; vision; hearing) If Disabled, Enter Brief Description.
If Disabled, INTERESTED IN LEARNING MORE ABOUT BEING A PLAINTIFF? YES NO Please read " Understanding the word Plaintiff" & "Shopping Barriers" on main page.
Do you use a Service Dog? Yes NO Name:
Donation:	appreciated, but not required (by mail)
Please tell us how or from whom you heard about "Access Now" (If from the Internet, please tell us the site):