CONNECTICUT "NUTMEG" STATE CHAPTER MYASTHENIA GRAVIS FOUNDATION OF AMERICA, INC. MEMBERSHIP RENEWAL FORM FOR YEAR 2012
Name: _____________________________
o Patient o Relative o Friend o Other
Address: ___________________________
City: ___________________________
State: _____
Zip code: _______________ + ___________
Phone number: ______________________
Email address: _______________________
o Enclosed is my Annual Membership Dues of [TEXT]nbsp; 20.00
o Enclosed is my Lifetime Membership Dues of [TEXT]nbsp; 200.00
o I am enclosing an additional donation of [TEXT]nbsp; ____________
Total Enclosed [TEXT]nbsp; ____________
o Dues waiver requested
o Please remove me from mailing list
I WOULD LIKE TO RECEIVE “THE NUTMEG” VIA o Regular US Post Office mail o E-mail
Please make checks payable to:
CT "Nutmeg" State Chapter, MGFA
Send to: CT "Nutmeg" State Chapter, MGFA
P.O. Box 91
Clinton, CT 06413-0091
Donations to our chapter are a nice way to honor a special person you know while contributing to a good cause. If you would like your donation in honor of or in memory of someone, we will send an acknowledgement (no amount indicated). Please complete the following:
In honor of: ______________________________________________________
Donation is from:
___________________________________ Please send Acknowledgement to: Name: _____________________________
Address: __________________________
___________________________________
In memory of: ____________________________________________________
Occasion: o Birthday o Holiday o Anniversary
o Wedding o Other: __________________________
Thank you for your support and donations. We appreciate your continued support in helping us to HELP YOU!
Download the form below:
Membership Form