Untitled Page

Membership Application/Renewal/Contributions Form

Please fill this Membership application and mail with your payments to the chapter office. Your membership starts the day we receive your membership fee in the office.

Date of application or renewal:
Contribution: $
In memory of:
In honor of:

First/Middle/Last:
Payment Amount: (check only)	$
Address:
City:		State: Zip:
Home Phone:
Work Phone:		Please make the checks payable to: Lupus Foundation of America Pacific Northwest Chapter 1207 N. 200th St. Suite 214 Shoreline, WA 98133
Email:

I am a lupus patient:

Female Male

I am a relative of a lupus patient:

Relationship:

Membership:

New Renewal

Address Change:
Individual ($20.00/Year):
Family ($30.00/Year):
Professional ($30.00/Year):
Courtesy ($0.00/Year):
I would like my name included in the newsletter:
I would like to remain anonymous:
Please delete my name from mailing list:

Yes! I'm interested in helping With:
Health Fairs	Phoning
Mailing	Lupus Walk
Newsletter	Office Help
Publicity	Outreach
Fundraising	Board of Directors
Other

If you have an account with paypal, you can also pay your membership dues through www.paypal.com.

Lupus Foundation of America, Pacific Northwest Chapter is a tax-exempt charitable organization under IRS Code (501)-(c)-(3). Your Payment receipts are sent in the mail.

1207 N. 200^th St. Suite 214, Shoreline, WA 98133 Office(206) 546-6785 Fax(206) 546-8946