National Fibromyalgia Partnership

Membership Form

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

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

                                        ___Please check here if this is a gift membership

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

Name:_______________________________________________________________________

Address:_____________________________________________________________________

City:_____________________State/Province:________Postal Code:___________________ 

Country (if not U.S.A.)____________________ Phone:_______________________________

Address:____________________________________________________________________

City:_____________________State/Province:_________Postal Code:_________________

Country (if not U.S.A.) ____________________ Phone:_____________________________

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

Account Number:__________________________________ Exp. Date:___________

Cardholder:_________________________Signature:__________________________