ALLIANCE MEMBERSHIP INFORMATION
  Please Print Clearly
Name:
Company (if applicable):
Address:
City: __________________________________ State:_______ Postal Code: ______________
County: ______________
Optional Membership Survey
Your answers to these questions are confidential and optional. Your answers will be useful for describing in a general way who the Alliance members are.

1. Organization(s) you belong to (if any):

2. Are you currently registered to vote?

YES_______ NO_______

3. Are you (check one):

____A person with a disability ___A person without a disability

4. How do you mainly get to places you most frequently go? (check one)

____ Public transportation (bus, paratransit, shared ride)
____ My own vehicle
____ Ride with family, friends, etc.
____ Agency/organization transportation vehicle
____ Other (Please describe)

Mail completed Application form to:
John Tassone
Center for Independent Living of Central PA
207 House Avenue, Suite 107
Camp Hill, PA 17011

Thank you for your interest!