Print out this application and submit it to the address below.

Membership Application                  

     Name_______________________________           

     Address_____________________________     

                  _____________________________     

     City________________________________            

     State/Province_________________        

     Zip Code/Postal Code___________

     Phone *____ (____) ______________  
      * Outside the US, please include the country code


Annual Contribution Categories (Tax Deductible)

     Membership (US).....................................$30   
     Membership (International).................US$40   
     Supporter..................................................$50
     Sponsor...................................................$100
     Patron......................................................$500
     Benefactor..............................................$1000+

      ____ Please check if you want your donation to be anonymous

     Please earmark my extra donations of $______ for:

     Research ______   Education ______   General ______  
     Helping other PWC _____

     Awareness (RESCIND) _____   Advocacy _____    
     CFIDERS______


For past issues of the NCF Forum newsletter (US$7 each) specify which issue(s):
  
            ______________________________________________________

send to
NATIONAL CFIDS FOUNDATION
103 Aletha Rd.
Needham, MA 02492  USA