ALDA Puget Sound

Association of Late Deafened Adults
Membership Form

I wish to become a member of ALDA Puget Sound

__________ 1) ALDA Puget Sound Dues $15.00

                      (Pro-rated from Sept 1 @ $1.25/Mo)

__________ 2) Donation to ALDA Puget Sound Tax Deductible

__________ 3) ALDA Inc Membership (Under 62, $25.00, 62+ $20.00)

__________ Total

NAME: __________________________________________________________

ADDRESS:  ______________________________________________________

 ________________________________________________________________

PHONE: ___________________________________ TTY (Yes or No):  ______

E-MAIL: _______________________________________

BIRTHDAY and MONTH ONLY ____/____

_____ Check line if you do NOT wish your name/address printed in the ALDA Puget Sound   membership directory.

Please mail this form & check payable to ALDA Puget Sound to:

ALDA Puget Sound

7943 13th Ave SW