Individual Membership Form
Personal Information:
Name:
Address: Apt #:
City:
State: Zip Code:
Telephone: TTY Voice Both
E-Mail:
Please check one. Are you:
Deaf/Hard of Hearing
Hearing
Please state your birth date:
Please choose one membership type:
$125 - Life Membership*
$25 - Five-year Plan Life Membership*
$25.00 per year - Annual Membership*

*PSAD Newsletter subscription is NOT included.
Credit Card Information:
  Full Name on Credit card:
  Card Type:
  VISA MasterCard American Express
  Card Number:
  Expiration Date:
  To prevent credit card fraud, we verify all credit card numbers with the cardholder's name and address. If the billing address for the card is different from the previous page, please enter the card information here
  Check this box if your billing address is the same as your billing adddress.
  Check this box if your billing address is the different from your billing adddress.
  If you checked second box, Please fill your billing address below:
Address: Apt #:
City:
State: Zip Code: