| Name: |
_______________________________________ |
| Address: |
_______________________________________ |
|
_______________________________________ |
| City: |
_______________________________________ |
| State: |
_______________________________________ |
| Zip: |
_______________________________________ |
| Phone: |
_______________________________________ |
| Email: |
_______________________________________ |
|
|
| Please Circle One: |
New
Member
Renewal |
|
|
| ________ |
We like to welcome our new members. Please check at
the left if you DO NOT want a Welcome call from us. |
| Enclosed are dues for (please check one): |
 | Personal Membership $10 |
|
| Personal Membership two-year renewal $20 |
|
| Professional Membership $20 |
|
| Professional Membership two-year renewal $40 |
|
|
| Additional Donation $ _______ |
| TOTAL Enclosed: $ _________ |
| (please make checks payable to Infertility
Focus, Inc.) |