The Women's Law Center of MAryland, Inc. Membership Application Form

Please print and complete the following information:

___ YES! Sign me up as a member of the WLC ($50)
___ YES! Sign me up as a student member! ($15)
___ Enclosed is an additional contribution of $_______________
___ My employer will match this gift. Enclosed is the appropriate gift from my employer.
___ Please contact me on how to include the WLC in my estate plan.
___ Please contact me about volunteer opportunities.
$______________ Total Amount Enclosed


Name: ________________________________________________________________
Title: __________________________________________________________________
Occupation: ____________________________________________________________
Area of Concentration: ___________________________________________________
Company/Firm/Organization: ______________________________________________
Address: ______________________________________________________________
City: _________________________________________________________________
State: ________________________________________________________________
ZIP Code: ____________________________________________________________
Work Phone: __________________________________________________________
Home Phone: _________________________________________________________
Fax: ________________________________________________________________
Email: _______________________________________________________________
Check Enclosed?: ___________
Credit Card Information: (if ordering by credit card)
Card Number: ________________________________________________________
Card Type (Master Card, Visa): __________________________________________
Expiration Date: ______________________________________________________

Signature: ____________________________________________________

Please return form with check payable to:

The Women's Law Center of Maryland, Inc.
305 West Chesapeake Ave., Suite 201
Towson, MD 21204

or fax your credit card order to: 410-321-0462