Use this form to become a member of the Cole Resource Center.  Please print and complete form and fax (# 617-855-3666) or mail to:

Cole Consumer Resource Center
115 Mill Street
Belmont MA 02478.

Please check one or more of the following:

Diamond Member $5,000    __________
Emerald Member $1,000     __________
Ruby Member      $500        __________
Sapphire Member $300       __________        $100_________         $50_________       $__________(any amount)

Your gift is tax deductible (nonprofit #04-328-2088)

Member Mailing Information::

Name:             ____________________________________________________________________
Address:          ____________________________________________________________________
City, State Zip ____________________________________________________________________

VISA/MC/AE # __________________________________________________________________

Expiration Date _______________                        Signature_________________________________

Please check here if you would like to remain anonymous:_____________

The following are for confidential office use ONLY:

Your Phone Number: ( ___ ___ ___ ) ___ ___ ___--___ ___ ___ ___
Your email address: _____________________________

__________________________________________________________________________________________

OFFICE USE ONLY -- Payment received _____/_____/_____ by ________