CHOROIDEREMIA RESEARCH FOUNDATION MEMBERSHIP FORM
Membership is $20 (US
Currency) per year or $250 for a lifetime membership and includes you and any
member of your household 18 years of age or older. All information will be kept
strictly confidential, and will not be released without written permission.
Your Name:____________________________________________________________
Address:
______________________________________________________________
City:
_______________________________ State/Province: ____________________
ZIP/Postal Code:
_____________________ Country: __________________________
Email:
___________________________________________ Phone: __________________________
Please list other members
of your household (18+ years) included in this Membership:
Name:
_______________________________________ Age: ___ Relationship:
_________________
Name:
_______________________________________ Age: ___ Relationship:
_________________
Please check one: I have
Choroideremia A CHM
carrier A
friend A relative of a CHMer
May we contact you
regarding Choroideremia? Yes
No
Please check type of Membership:
One Year ($20) Lifetime
($250)
Payment Method: Cash Check Money Order Credit Card
Please make checks or money
orders payable to: Choroideremia Research Foundation, Inc.
Credit Card information:
Visa Master Card American Express Discover Novus
Card #
___________________________________________________ Exp. Date _______
Billing Address Zip Code:
___________ CW
# (3 digit number on back of card): _______
Name as it appears on card:
__________________________________________________
Signature:
________________________________________________________________
Please send check or money
for $20 (US Currency) to:
CHOROIDEREMIA RESEARCH
FOUNDATION, INC.
Notice to Consumer
regarding TeleCheck, A First Data Corporation: By (1)
submitting your check for payment, and (2) choosing NOT to exercise your right
to OPT-OUT, as specified below, you are authorizing the payee, or its agent,
upon receipt of your check, to convert the check to an electronic payment item
or draft and to submit it for payment as an ACH debit entry or draft to your
account, in accordance with the same terms and conditions as your check.
I
want to OPT-OUT
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