Check #  _____________

 

            The Houston NeuropathySupport Group       Check Date ___________

2009 Membership Form

$15.00

 

Mail to: 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_____________________________________________________________

                                         Please PRINT Clearly

 

Dues  $15          Donations $__________    TOTAL ENCLOSED  $________

 

 

Please make Checks Payable toThe Houston NeuropathySupport Group

They will be deposited in our business account. There is no charge for spouses.

 

We are currently a nonprofit incorporated group in the state of Texas and a
nonprofit 501(c)3 with the federal government.

 

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

 

We look forward to providing interesting and informative programs during 2009.