Access Now Membership Form
Last Name
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First Name
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Address Line 1
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Address Line 2
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City
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State
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Zip Code
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Phone
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Fax
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Email Address
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Disabled Status
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Disabled
Non Disabled
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If Disabled, give brief description: (mobility, wheelchair-user, part time/full time; vision; hearing)
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If Disabled, INTERESTED IN LEARNING MORE ABOUT BEING A PLAINTIFF?
Please read " Understanding the word Plaintiff" & "Shopping Barriers" on main page.
Please Choose from Drop Down List
Yes
No
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Do you use a service dog?
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Yes
No
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If yes, what is your service dog's name
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I would like to make a donation. Please enter amount
Donations can currently be mailed to Access Now
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Please tell us how or from whom you heard about "Access Now" (If from the Internet, please tell us the site):
Where Did You Hear About Us? (name of person or address of website)
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