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 01701

Or fax to 1-617-776-3243