Full Name: _______________________________________________________

Mailing Address: _________________________________________________

_________________________________________________

Telephone: _______ - _______ - _________ TTY Voice Both

Videophone: _______ - _______ - _________

FAX: _______ - _______ - _________

E-Mail: _____________________@____________________________________

Annual Membership Fee: $20.00 
The Leather Archives & Museum, Donation: $5.00
Total: $25.00

Signature: _________________________________ Date: ______________
Signature is required for membership.

Do you want your name and e-mail to be listed on public directory?  No Yes

Please mail it to:
International Deaf Leather
Membership Dept
c/o: Tom Smith
3449 W 119th St
Down
Cleveland, OH 44111,

Any Questions, Contact us at membership@internationaldeafleather.org

Office Use Only:  Received by: _____________ Membership # ________
                  Amount PAID: _____________ Date: ________________