MEMBERSHIP
    APPLICATION

    NAME: _______________________________________________

    AFFILIATION: __________________________________________

    ADDRESS: ____________________________________________

    CITY / STATE / ZIP: _____________________________________

    HOME PHONE:______________ WORK PHONE: ______________

    E-MAIL: ____________________________________________

    I am joining as an:

      ___ Individual Member ($25)
      ___ Professional* Member ($50)
      ___ Non-Profit or Not-for-Profit Organization ($100)
      ___ For-Profit Businesses ($500)

      * Professional membership applies to individuals who are employed by a Health and/or Human Services business, are in private practice, or who hold a professional degree or license in a related field.

    Send this form along with a check for the appropriate amount to:

      Rainbow Access Initiative
      PO Box 9144
      Niskayuna, NY 12309

    NOTE: Fees are payable once a year and due January first. Anyone joining prior to January 1, 2005 will not have their membership due until January 1, 2006.

    Rainbow Access Initiative (RAI) is committed to equal opportunity in all aspects of employment. This includes recruitment, hiring, training, promotion, compensation, transfer and other terms and conditions of employment, of all persons regardless of race, age, religion, disabilities, national origin, gender or sexual preference.

    Discrimination on the basis of race, ethnicity, color, creed, religion, national origin, income status, disability, sexual identity, and gender expression is prohibited in the practices and procedures of Rainbow Access Initiative.