Membership Application

June 1, 2001 thru June 1, 2002

Name: _

Organization:

Title: ___________________

Address:

City: State:

Zip: _______________________

Home phone ( ) Work( )

Fax ( ) _________________

Check membership type: Individual ($5) ________

Organization ($25) __________ Friend ($100) ______ Supporter ($500)

______ Benefactor ($1000) _____________ Other $_________

Please fill out this form, make your check payable to DNOS and mail it to:

DNOS 118 W. Sunrise Avenue Trotwood, Ohio 45426

DNOS memberships are renewed annually. This membership will be good until June1, 2002.

DNOS is a non-profit organization so your contribution is tax deductible

Disability Network of Ohio-Solidarity would like to thank you for your financial contribution and continued support.

DNOS Board of Trustee’s

Ray Jones, President

Office use only: Date

Check Number ____________