California Coalition Membership Form
Print this out and send with check/credit card information to CBC, 1017 L Street, #288, Sacramento 95814.
_________________________________________________________________________
Name
_________________________________________________________________________
Address
_________________________________________________________________________
City, State, Zip
_________________________________________________________________________
Phone/Fax
_________________________________________________________________________
E-mail Address
_________________________________________________________________________
Workplace/City
_________________________________________________________________________
Interests
Membership Type
[ ] New
[ ] Renewal
[ ] Student/Senior/Living Lightly ($15)
[ ] Introductory ($25)
[ ] $1/week for better bicycling ($52)
[ ] $2/week for better bicycling ($104)
[ ] $1/work day for better bicycling ($250)
[ ] Other ______________________
Payment Type
[ ] My check for the above amount is enclosed.
[ ] Please bill my credit card for the above amount. My credit card is a:
[ ] VISA [ ] Master Card
My credit card number is: _________________________________________
My credit card expires: Month _________________Year_________________
Membership Premiums
[ ] I'm joining at the $52-$99 level. Please send me CBC's "Bike Voter" T-shirt in the following size (circled):
Small Medium Large Extra Large
[ ] I'm joining at the $100 or greater level. Please send me a CBC Cap (one size fits all).
[ ] I'm joining at the $52 or greater level, but don't want a premium.
[ ] Please do not share my name with other mailing lists.
