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.

Signature:____________________________________________________________

PLEASE PRINT

Name(s)________________________________________________________

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

Home Phone:____________________________ Cell 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: ___________________________

Current Residence:________________________________________________________________________________________________________

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.)         

$10 per person       $_______________                                                                                                                              

Donation to PART   $________________                                                             

Total Amount Paid $ _______________         Please make check or money order payable to PART.

Mail check/MO and completed form to:  PART Treasurer, P. O. Box 9733, Austin, TX 78766-9733