We need your support!  To become a member of the FSH Society or to make a contribution, please print this page
and send to:   The FSH Society, Inc. BBRI R353, 64 Grove Street, Watertown, MA 02472 USA

Year 2008 Membership Application

Name                     __________________________________________________________________

Address                 __________________________________________________________________

City/State/Zip         __________________________________________________________________

Province/Country      __________________________________________________________________

Phone Day             (_______) _____________________

Evening                  (_______) _____________________

e-mail                      ____________________________________________________________

Use space below for address changes, specifying interested individual, specifying title and affiliation, corporate designation or for any other comments you may have:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________
 

Individual & Family Membership Organizational & Corporate Membership

O I              $50 +
O II             $100 +
O III            $250 +
O IV           $500 +
O V            $1,000 +
O Other      $_________

 O I              $1,000 +
O II             $5,000 +
O III           $10,000 +
Professional Membership Non Membership Donation
   
O I               $125 +
O II              $250 +
O III             $500 +		 O Other       $___________

 
  Research & Education Fund Donation
  O Other        $___________

Bill my Credit Card: 
O AMEX  O VISA  O MasterCard  O Discover

Account No.     ______________________________
Card Expiration Date   (MM/YY) ______ / ______ 
Signature:      _______________________________

Repeat the Contribution Amount?   
O Monthly    O Quarterly     O Semi-Annually 

 
 
Please make checks payable to the FSH Society TOTAL ENCLOSED:            $____________
 
O  In Honor of:   ______________________________

O  In Memory of:  _____________________________

O  Please check here if you would like your gift
     to be anonymous		   O Please check here if you would like your
      membership or donation acknowledged in the
      next issue of the FSH newsletter.



 

Please make checks payable to the FSH Society and send contributions to:
Nancy Van Zant, Executive Director
FSH Society, Inc., BBRI R353, 64 Grove Street, Watertown, MA 02472 USA