Check # ______________

Check Date ___________

2008 Membership Form
The Houston NeuropathySupport Group
$15.00
Mail to:
Mr. John Longo
13819 Taylorcrest Rd.
Houston, Texas  77079
    281 493-3695

PLEASE PRINT:

Name____________________________________________________________
              Mr. Mrs./Ms.                        First                                   Last

Spouse___________________________________________________________
                 Mr./ Mrs./ Ms.                    First                                  Last

Address__________________________________________________________


City________________________    State_________  Zip Code______________


Home Phone___________________   or_Business Phone___________________


E-Mail___________________________________________________________


Dues  $15          Donations $__________    TOTAL ENCLOSED  $__________

Please make out Checks or Money Orders for $15 to The Houston NeuropathySupport Group and they will be deposited in our business account. We are currently a nonprofit incorporated group in the state of Texas and a federally recognized 501(c3) so membership dues are tax deductible .

Mail checks to: John Longo, 13819 Taylorcrest Rd., Houston, TX 77079

We look forward to provide interesting and informative programs during 2007.

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