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:_______________________________

 

Billing Information (if different from above):

Address:____________________________________________________________________

City:_____________________State/Province:_________Postal Code:_________________

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

 

-----------------------------------------------------------------------------------------------------------

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

___ Please charge my:   Visa    Mastercard

Account Number:__________________________________ Exp. Date:___________

Cardholder:_________________________Signature:__________________________

(Mail to: NFP, Inc., P.O. Box 160, Linden, Virginia 22642 USA)