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National Fibromyalgia Partnership |
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Membership Form |
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[check one] |
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___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.)
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___Please also check here if this is a gift membership or renewal |
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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:__________________________
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* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ___ 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)
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