TDI's Membership Form

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Household/Residential Membership Application

Category	One Year	Two Years
Regular	$25.00	$45.00
Seniors (age 60 +)	$22.50	$40.50
Students *(Please provide proof of full-time student status)*	$15.00	$27.00

Your First Name:
Your Last Name:
Spouse's Name:
Street Address:
City: State: Zip:
Home Phone Number: TTY Voice Both
Work Phone Number: TTY Voice Both
Fax #:
Pager #:
Your E-mail Address: (required for TDI's eNotes)
Spouse's E-mail Address: (if given, your spouse will also get TDI's eNotes)
Your Instant-Messaging (IM): (if any) Service: User ID:
Your website:
Your choice for listing in the directory?
Do you want to be listed in the electronic directory?
Do you want your address shared with any kind of service?
Membership Fee:
Do you want to purchase 2003 "Blue Book" directory for only $10.00? (valid only with purchase of this membership)
Contribution (Thank You!):

Payment: C.C. Expiration Date:
Credit Card Number: (mm/yy)
Your name as shown on credit card:

NOTE: Fill in the fields before printing this Form out.
Sign your name below before faxing or mailing the printed Form to:

                         TDI
             8630 Fenton Street, Suite 604
            Silver Spring, Maryland 20910
                               U.S.A.
                     301-589-3797 FAX

Cardholder's Signature: ____________________________________