National Fibromyalgia Partnership
 

Membership Form
 

[check one]

 

 

 

___New Membership--U.S./Canada/Mexico ($25/yr.)

___New Membership--All Other Countries ($30/yr.)

OR

___Renewal--U.S./Canada/Mexico ($25/yr.)

___Renewal--All Other Countries ($30/yr.)

 

___Please also check here if this is a gift membership or renewal

 

                              

                               

Please mail "New Member Packet" and Fibromyalgia Frontiers  to:

Name:_______________________________________________________________________

Address:_____________________________________________________________________

City:_____________________State/Province:________Postal Code:___________________ 

Country ____________________ Phone/Email:__________________________

 

Billing Information (if different from above):

Name:_______________________________________________________________________

Address:_____________________________________________________________________

City:_____________________State/Province:________Postal Code:___________________ 

Country ____________________ Phone/Email:__________________________

 

*   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *  

___ I am enclosing my check/money order payable to "NFP, Inc." (U.S. dollars)

___ Please charge my:     q Visa  q Mastercard  q Discover

Account Number:__________________________________ Exp. Date:___________

Cardholder:_________________________Signature:__________________________

(Please mail this form with your payment to: NFP, Inc., P.O. Box 2355, Centreville, Virginia 20121 USA)