Bike-Walk Alliance of NH Membership Application

To join the Alliance, please print this form, fill in the blanks, then mail it with your

payment the address below.

Name__________________________________________________________

Address ________________________________________________________

Address ________________________________________________________

City_____________________________State_______Zip code_____________

Work Phone________________________________________ Ext. _________

Home Phone_________________________________ Unlisted?  (Y/N) ______

E-Mail Address ____________________________________________________

____ New Membership, ____Renewal Membership

MEMBERSHIP CATEGORIES:

BWA-NH memberships are available at the following annual rates.

___ $250 Benefactor: includes gift

___ $100 Sponsor: includes gift

___ $75 Contributing: includes gift

___ $50 Supporting

___ $35 Basic

___ $_______ Other: ____________

As special thanks for joining the BWA-NH for $75.00 or more, you will

receive a free copy of LAB's Guide to Safe and Enjoyable Cycling, a $15.00 value.

$ ___________ TOTAL PAYMENT

METHOD OF PAYMENT (Check one)

___ Check number: ____________________ (Make checks payable to "BWA-NH")

___ Cash   (Received by:____________________ Date:_______________)

I can help with:

___ general, ___ communications/publications, ___ fundraising,

___ events, ___ advocacy/legislation, ___ touring, ___ education,

___ commuting, ___ bikeways, ___ other (____________________)

I would like to join a regional committee or chapter:

___ Seacoast Region, ___ Merrimack Valley Region, ___ Dartmouth/Lake Sunapee,

___ Monadnock Region, ___ White Mountain Region, ___ Lakes Region,

___ Great North Woods Region, ___ Other (______________)

What type of cyclist are you?

___ commuter, ___ competitive/racing, ___ tourist, ___ messenger

___ utilitarian (shopping, errands), ___ recreational, ___ mountain biking,

___ other (____________________)

I (we) will not hold the BWA-NH or GSW, its officers or members responsible for any injury, damage, or loss incurred while participating in any BWA-NH/GSW functions.

Signature 1 ___________________________________________

Signature 2 ___________________________________________

(Parent or guardian if under 18)

Date ____________________

Mail to:

Bike-Walk Alliance of NH

Membership Chairperson

163 Manchester Street, Suite C

Concord, NH 03301-5143

Thank you!

File:  memb-form-06.doc