BIA of Rhode Island, Inc.   M E M B E R S H I P   F O R M

___ New Member?      ___ Renewal?

Member Name ____________________________________________

(Company Name) __________________________________________

Address __________________________________________________

City ______________________  State ____ Zip __________________

Home Phone No. (______) ___________________ Work Phone No. (______) ___________________

E-Mail Address: __________________________________

Professional Field: __________________________________________

___ Basic $35.00      ___ Professional $50.00
___ **Corporate $200.00  ___ Entry $5.00*

Membership will not be denied due to inability to pay membership fees.
*(A reduced rate for those persons with a brain injury or a family member who has limited resources.)
** Includes two individual memberships, print both names.

Payment

___By Check  or     ___MasterCard   or     ___VISA     

Card No.: _______________________________   Expiration Date: ____________

Signature: __________________________________________________________

Please make checks payable to: Brain Injury Association of Rhode Island, Inc.
Please mail completed form with your contribution to:

BIA of Rhode Island
935 Park Avenue, Suite 8
Cranston, RI 02910-2743

Thank you for your support!  BIARI is a  501(c)(3) non-profit organization
Community Health Charities of New England, SECA + Combined Federal Campaign #2580