Two Wheels, One Voice.

Bike Miami Valley Membership Form

Join Bike Miami Valley to allow us to continue to help you! Complete this form and return it today. Just print off this form, fill it out and return it to Bike Miami Valley, along with your fully tax deductible donation.

Name ________________________________

Address: ______________________________

City __________________________________

State ___________ Zip __________________

Phone ________________________________

Email _________________________________

Donation Level (circle one):

Student/Retired   $15/annually   

Individual            $25/annually  

Family                 $35/annually

Corporate            $100/annually

Supporter            $150/annually

Lifetime               $500/one time

Please indicate the amount you are donating:  $ ______

May we list your name as a sponsor to be included on our web page and newsletter?

Yes ___  No ___ 

How would you prefer to receive your quarterly Bike Miami Valley newsletter?

____ E-mail ____ Fax

If you'd prefer e-mail please provide your e-mail address here:

___________________________

Would you like to receive an acknowledgement letter for tax purposes?

Yes ___  No ___

Thank you for supporting Bike Miami Valley!

Bike Miami Valley

P.O. Box 246

Dayton, OH 45402-0246