Date of application or renewal:

Contribution: $

In memory of:

In honor of:

Name:

Payment Amount:
(check only)

$

Address:

City:

State: Zip:

Home Phone:

Work Phone:

Your membership starts the Day your membership fee is received in the office.

Please make checks payable to:
Lupus Foundation of America
Pacific Northwest Chapter
1207 N. 200^th St. Suite 214
Shoreline, WA 98133

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.

Email:

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 Member

Other