Join the Mass Chapter of the Autism Society of America

_____  Individual Membership____________________________$15.00

_____   Family Membership______________________________$20.00

_____   Corporate/Organizational Membership_____________$50.00

_____   Additional Donation_______________________________$

_____   Employer Matching Donation_______________________$

_____   I will ask United Way to send to ASA Mass Chapter

(For National Membership, please to go www.autism-society.org)

Name:   _____________________________________________________

Address: _____________________________________________________

City/State/Zip: _______________________________________________

Telephone: ___________________________________________________

E-Mail Address: ________________________________________________

Mail to:

Autism Society of America, Mss Chapter

C/O Autism Services Association

47 Wallnut St., Wellesley, MA 02481