NAME ____________________________________________________

ADDRESS
____________________________________________________

____________________________________________________

PHONE NUMBER ______________________

E-MAIL ADDRESS ______________________

FAX ______________________
 
 

I want to join. Dues are $10 to $25 (as able to afford). I am enclosing $_______
 
 

Mail to:
DISABLED IN ACTION of Metropolitan New York
P.O. Box 30954, Port Authority Station
New York, NY 10011