False Memory Syndrome Foundation
1955 Locust Street, Philadelphia, PA 19103-5766
Membership/Subscription Form
The FMS Foundation has been granted tax exempt status by the IRS. Contributions are tax deductible. The identity of donors is confidential.

Please fill out all appropriate items & mail payment to:

FMS Foundation, 1955 Locust Street, Philadelphia, PA 19103-5766
 

Contribution amount (tax deductible): $______________________________

Method of payment:

__ Check or Money Order: Payable to FMS Foundation in U.S. dollars.

__ Visa: Card number & expiration date:   _______/_______/_______/______ exp.______

__ Mastercard: Card number & exp. date: _______/_______/_______/______ exp.______

Signature (for credit card payment only): ___________________________

Attn.: All Foreign & Canadian payments may only be made with a Credit Card, a U.S. dollar money order, or a check drawn on a U.S. dollar account.
 
Name: ___________________________________________________ 

Address: ___________________________________________________ 

___________________________________________________ 

___________________________________________________ 

Phone (H): (______)________________ (W): (______)________________ 

Fax: (______)________________ E-mail:______________________ 

 For Office Use Only

Check #:____________

Amount: $__________
 

Please remember to print, fill out, and include the survey as well. Thank you for your support!