Print out this application and submit it to the address below.

Membership Application                  

     Name _______________________________

     Address _____________________________

     ____________________________________

     City _______________________________

    State / Province ____________________

    Zip Code / Postal Code ___________

     Phone * ____ (____) ______________

      * Outside the US, please include the country code


Annual Contribution Categories (Tax Deductible)

     Membership (US).....................................$30
     Membership (Canada).............................$45
     Membership (International)......................$50
     Supporter..................................................$50
     Sponsor...................................................$100
     Patron......................................................$500
     Benefactor..............................................$1000+

      ____ Please check if you want your donation to be anonymous

     Please earmark my extra donations of $______ for:

     Research ______    Education ______    General ______
     Helping other PWC _____

  For past issues of the NCF Forum newsletter (US$7 each) specify which issue(s):

      ________________________________________________________

send to
NATIONAL CFIDS FOUNDATION
103 Aletha Rd.
Needham, MA 02492   USA