LDA-CA Membership Application

Membership Type
___ I want to become a member of LDA-CA.  Dues are $45.   Renewals are billed in
    September by LDA-CA.   (Memberships received after May will not be  due  for
    renewal until the following year.) 

___ I do not want to become a member just now,  but I do wish  to  subscribe  to
    "The GRAM" (U.S. only). The nonmember subscription rate is $15 per year; $25
    for two years. Enclosed is $ _________ for my nonmember subscription.

___ I live outside of the  United  States  and wish to subscribe to  "The GRAM".
    The international subscription rate is $30 per year.

___ I wish to make a donation to LDA-CA.  Amount of donation $__________________


Contact Information
Name____________________________________________________________________________

Address_________________________________________________________________________

City/State__________________________  Zip_________  E-Mail______________________

Home Phone__________________  Work Phone__________________  Fax_________________



Profile
___Parent   ___Professional   ___LD Adult   ___Other


Credit Card Information
Card Type:     ____MasterCard     ____Visa

Account Number___________________________________ Expiration______________

Account Name____________________________ Signaure_________________________



Sending Options
FAX with Credit Card information or mail with Check or Credit Card information:
         LDA-CA
         P.O. Box 601067                          FAX 916-725-8786
         Sacramento, CA 95860