National ME/FM Action Network Membership Application Form 512, 33 Banner Road, Nepean, ON  K2H 8V7,  Canada Phone:  613-829-6667        Fax:  613-829-8518
Name                                                                  Date                           Phone
Address                                                                                         City
Prov/State                                  Postal/Zip Code                               Country
Email                                                        Website
New member        Renewal
I have ME/CFS ,     FMS .     Year of diagnosis:  ME/CFS                  FMS
I would like to volunteer my time ,  ideas  , other
Annual Membership fee   $ 25.00 (includes newsletter)		* Tax receipt will be issued               for donations.
Quest Collection II (1999-2003)                         $ 38.00
Quest Collection III (2004-2008)                         $ 38.00		You can designate your
TEACH-ME                         $ 22.00		United Way donation to go to the
ME/CFS Case Law list      $ 60.00		National ME/FM Action Network
CPP Guidelines                 $   7.00
* Donation		Charitable tax no.: (BN) 89183 3642 RR0001
Total
Payment:   cheque                  Master Card                          Visa
Card number:   _ _ _ _   _ _ _ _   _ _ _ _   _ _ _ _
Expiry date:                         Card holder (please print) :
Signature:
Cheques payable to:  National ME/FM Action Network,                                      512, 33 Banner Road, Nepean, ON  K2H 8V7,  Canada
Medical & legal professionals & support group leaders:  please complete 2nd page.