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MEMBERSHIP APPLICATION – Information Packet

Print this form out and mail it to the address below.

           
(Mr., Mrs., Mr. & Mrs., Miss or Ms.)

NAME _____________________________________________________DATE ___________________________

ADDRESS ________________________________________________________  APT# _____________________

CITY _______________________________________  STATE _______________  ZIP ______________________

COUNTY ___________________________________  

PHONE # ______________________________________

EMAIL ADDRESS _____________________________________________________________________

OPTIONAL INFORMATION:Doctor’s name  
______________________________________________________________________________________________

 

          Lupus Patient           Family Member           Friend           Health Professional                Other

       AGE GROUP:        Under 20    20s      30s        40s        50s        60s        70s, plus

        CHECK ONE:        p  NEW MEMBERSHIP    p  RENEWAL

       MEMBERSHIP                       $20 Single        $25 Family        $50 Sponsor
       DUES (Please Check One):        $100 Supporting                      $1000 Lifetime


 

            May We Publish Your Name in Newsletters, etc.?         Yes         No

            Would you like to volunteer?         Yes         No

Please mail this form with your membership dues to:

LFA, NORTH TEXAS CHAPTER
P. O. BOX 810310
DALLAS, TX 75381-0310

 

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