MEMBERSHIP FORM FOR YEAR 2012
Name:
MG Patient: Relative Friend
Family Member Professional Other
Address:
City:
State:
Phone number:
Email address:
Enclosed is my Annual Membership Dues $20.00
Enclosed is my Lifetime Membership Dues $125.00
I am enclosing an additional donation of $
Total Enclosed $
( ) Dues waiver requested
( ) Please remove me from chapter mailing list
Please make checks payable to: Oklahoma Chapter of the MGFA or OKMGF
Mail to: Oklahoma Chapter Myasthenia Gravis Foundation of America, Inc.
4606 E 67th St S, Suite 100
Tulsa, OK 74136-4950
Donations to our chapter are a nice way to honor a special person while contributing to a good cause. If you would like your donation in honor of or in memory of someone, we will send them an acknowledgement card (no amount indicated). Please complete the following:
In honor of:
In memory of:
Occasion: Birthday Holiday Anniversary
Wedding Other:
Please send Acknowledgement to:
Name: __
City, State, Zip: ________________________
The Oklahoma Chapter of the Myasthenia Gravis Foundation of America, Inc. is a 501(c)3 non-profit
and donations are deductible under the extent of the law.
We appreciate your support in helping us to HELP YOU!