Contra Costa ARC Membership Application

Please print this form, complete it, and mail it to:
Contra Costa ARC, 1340 Arnold Drive, Suite 127
Martinez, CA 94553
THANK YOU!

Contra Costa ARC
Membership Application

You can count on my support
at the following level:

[] Student/Senior/Person with a disability ($8)
[] Regular Member ($25 to $100)

Hundred Plus Club

[] Member ($100 to $250)
[] Supporter ($250 to $500)
[] Sponsor ($500 to $1,000)
[] Patron ($1,000 +)

Note: Each Hundred Plus Club member is entitled to attend our
annual Community Service Awards Banquet as our guest, and
be entered in our Hundred Plus Club Drawing.

Name(s)___________________________________

___________________________________

Street Address_____________________________

City / State / Zip____________________________

Phone: Home_____________ Work_____________

Total amount enclosed $______________________

(Please make checks payable to Contra Costa ARC.)

Optional and confidential information:
[]Parent []Relative []Consumer []Professional []Friend

Charge my Contribution of $ ________________to my:

[]Visa []MasterCard Expiration date ____________________________

Account # ____________________________________________________

Signature _____________________________________________________

Contra Costa ARC is a 501(c)(3) non-profit agency.
Contributions are deductible to the full extent allowed by law.
Tax ID#: 94-1606 517

Questions: Phone 925-370-1818


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