My membership number is __________. (Use our Membership Search to find your number if you don't know it.)
Name: ______________________________________________________________________ Address: ______________________________________________________________________ Address2: ______________________________________________________________________ City: ______________________________ State/Province: __________ Zip/Postal Code: ______________________________ Country: ____________________ Email: ______________________________ Home Phone: ______________________________ Cell Phone: ______________________________ Planned Arrival/Departure Dates: ______________________________ Which hotel do you plan to stay in: ______________________________ Additional comments or questions: ______________________________________________________________________ Scooters ($240 including insurance)
$_____ regular scooter
$_____ heavy-duty scooter (for those weighing 300-450 pounds)Wheelchairs ($105 including insurance)
$_____ regular wheelchair
$_____ heavy-duty wheelchair (for those weighing 300-450 pounds)$_____ Total Amount
I am paying by (circle one):
Visa
MasterCard
Check [Make checks payable to Noreascon 4]
Card #_________________________________ Exp._________
Name on card ________________________________________
Signature ___________________________________________
Please Return This Form ASAP but No Later Than June 30, 2004 to:
Noreascon Four Handicapped Services
PO Box 1010
Framingham, MA 01701Or fax to 1-617-776-3243