Membership Application
LIFE Center for Independent Living

Date: ____________________

Name: ___________________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

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

E-Mail: __________________________________________________________


New or renewed Membership: (Please check one)

____ New Member
____ Renewed Member


Membership Levels: (Please check one)

____ $10 - Individual Membership (Discounts available for persons with disabilities)
____ $25 - Family Membership (3 or more members of the same family)
____ $50 - Not for Profit Business/Agency Membership
____ $75 - For Profit Business Membership
____ $200 - Lifetime Membership


Please accept my additional contribution of $________.


Preferred format for print materials: (Please check one)

____ Regular print
____ Large print
____ Braille
____ Diskette
____ Audiotape
____ E-mail


Preferred method of receiving mail:  (Please check one)

____ Mail
____ E-Mail



Please mail or deliver this Membership Application, along with your dues to our office:

LIFE Center for Independent Living
2201 Eastland Drive, Suite 1
Bloomington, IL 61704