Membership Application


Print this form and mail to:

CYSTINOSIS FOUNDATION
604 Vernon Street
Oakland, CA 94610
1-800-392-8458


Date: _______


		Indiviual		( )	$20

		Family			( )	$45

		Contributing		( )	$100

		Professional		( )	$250

		Patron			( )	$500

		Life			( )	$1,000

		Corporation		( )	$2,000

		Honor Circle		( )	$5,000



YES, I want to be a member of the CYSTINOSIS FOUNDATION.
Enclosed are my membership dues of $ ___________ .

NO, I do not want to be a member, but I want to contribute. 
Enclosed is my contribution of $ ___________ .

Name	____________________________

Street	____________________________

City	____________________________  

State   _______   Zip  _____________

Phone	____________________________


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