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).....................................$10
     Membership (Canada).............................$15
     Membership (International)......................$25
     Supporter..................................................$15
     Sponsor...................................................$20
     Patron......................................................$50
     Benefactor..............................................$100+

      ____ 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