PART MEMBERSHIP APPLICATION
(NOTE:  Membership year is from July 1 through June 30.)

Date: _______________   Amount Paid $____________________

[Check One]          (  ) NEW Member        (  ) Membership Renewal

I [We] agree to support the goals of PART.

Name(s)________________________________________________________

Address________________________________________________________
            (Street)                               (City)                    (State)                (ZIP)

Home Phone:_______________________ Work Phone___________________

E-mail Address:________________________________________

If you are a relative or guardian of a mentally retarded individual, please complete the following information on your family member:

Individual's Name: _____________________________ [  ] Male [  ] Female        Individual's Date of Birth: ________________

Present Residence Address:______________________________________________________

Your relationship (Check ALL that apply): 

[  ] Parent    [  ] Sister/Brother     [  ] Aunt/Uncle     [  ]  Guardian    

[  ] Other, please explain: ___________________________________

Dues are $10.00 per person   (NOTE: Dues and any additional contributions are tax deductible.)

Please make check payable to PART.

Mail check and completed form to:

PART Treasurer
P. O. Box 9733
Austin, TX 78766-9733