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LIFE Center for Independent Living

Date: ____________________

Name: ___________________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Telephone: (     ) __________    (Circle or highlight one)     Voice     TTY     FAX

E-Mail: __________________________________________________________


I would like to receive the following information: (Please check one)

____ Newsletters
____ Event and Workshop Announcements
____ Advocacy Updates
____ Annual Reports


Preferred format for print materials: (Please check one)

____ Regular print
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____ Diskette
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Preferred method of receiving mail:  (Please check one)

____ Mail
____ E-Mail


Please accept my voluntary contribution of $ ________.


Please mail or deliver this form to:

President, Board of Directors
LIFE Center for Independent Living
2201 Eastland Drive, Suite 1
Bloomington, IL 61704