Form

The Arc of Virginia

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The Arc of Virginia #6016

The Arc of Virginia Membership Form

Yes! I want to join The Arc of Virginia in ensuring that people with intellectual and related developmental disabilities are valued as classmates, coworkers, neighbors, citizens and friends.

Enclosed is my tax-deductible membership donation of: (mark one)

Individual	Organization
O $500 Patron	O $1000 Benefactor
O $250 Donor	O $500 Patron
O $100 Friend	O $250 Donor
O $50 Contributor	O $100 Friend
O $25 Member

I wish to contribute $ _____________

My organization would like to be a Business Partner and contribute: (mark one)

O $5000 "Arc Angel"	O $1500 Supporter
O $2500 Partner	O $1000 Benefactor
O $2000 Sponsor	O $500 Patron

Please make checks payable to The Arc of Virginia and mail to:
The Arc of Virginia, 2025 East Main Street, Suite 120, Richmond, VA 23223

NAME _________________________________________________________________________

ORGANIZATION _______________________________________ TITLE ___________________

ADDRESS ______________________________________________________________________

CITY _________________________________________ STATE ______ ZIP ______________

PHONE (W) ___________________________ PHONE (H) _______________________________

FAX ______________________________ EMAIL ___________________________________

Please share with us your special interest: (mark all that apply)

O Early Intervention	O Consumer Directed	O Advocacy
O Special Education	O Employment	O Litigation
O Family Support	O Residential