Name: (First, Middle, Last)

 ________________________________________________________

 Address: _________________________________________________

 City: ____________________________________________________

 State: _____     Zip: _________________

 Work Phone: _______________________

 Fax: ______________________________

 Home Phone: _______________________

 E-Mail: _________________________________________________

 NRA Membership:

 _____ Professional $132                 _____ Student $42

 NADBS:

 ______ Professional $30                 _____ Student $15

 Method of Payment:

 _____ Check                ______Mastercard            ______ Visa            ______ACH 

Credit Card # __________________________________________

 Expiration Date ________________________________________

 ACH: Monthly _________________________________________

 I Authorize the National Rehabilitation Association to debit to my checking or savings account.

 Send your completed application to:

National Rehabilitation Association

633 South Washington Street

Alexandria, VA 22314-4109