Print this form and mail to:
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 ____________________________