Dayton Microcomputer Association Membership Form - revised Apr. 19 2006
             Please - only one person per form.  Thank you.

Name ____________________________________________ Birth date ___/___/___
                                                             mo  da  yr
Address ________________________________________________________________

City _________________________________  State ____  Zip _________-______

Phone H (____)____-______________  Phone W (____)____-_____________x____

E-mail address _________________________________________________________

I want my name & address published in the club roster:  Yes [ ]  No [ ]

Name of DMA member who recruited me __________________________________

Current Member Y[ ]  N[ ]  Address Change [ ]  Today's Date ___/___/___

Membership number (from your DataBus mailing label) ___________________

                             Type of Membership
Application for: New [ ]   Renewal [ ]   Associate* [ ]   Internet [ ]

If applying for free student membership, please give school name and
student ID number. Free membership only for students under 22 years old.
School Name ____________________________ Student ID# ___________________

* A family associate membership is for an additional membership for a
member of your immediate family who is living in the member's household.
If this is a family associate membership, give name of regular member:
Regular member's name __________________________________________________

       Internet Service Application  ssh minutemaid.dreamhost.com
Provides: @dma.org address, Linux shell, personal non-commercial website, 
& more at no cost other than a one-time $10 setup fee.

Internet ID (8 char. max.)         1st choice ________________ [ ] $10
Usual default is last name & first initial (no caps or punctuation)
DMA reserves right to assign ID    2nd choice ________________

No account created w/o signed Internet Services Terms & Conditions agreement!

   Dues/Fees Note: A $10.00 fee will be charged for all returned checks.

Regular Membership $25 / year effective Apr. 1, 2003      1.) _______ x __yrs
Family Associate Membership $12.50/ year                  2.) _______ x __yrs
Student under 22 years old                                3.) [ ] FREE 
Please assign to me a user ID for Internet access         4.) [ ] $10
Total  Lines [1 or 2 x # years (3 yr. max. renewal)] + 4  5.)$_______

Write check to DMA, then send the check     Dayton Microcomputer Ass'n
and application to:  - - - - - - - - - >    PO Box 340402
                                            Beavercreek, OH 45434-0402

DMA Use only: Memb.# __________ Exp. __/_____ Processed _____________________