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| To complete this form - print out and return to: |
Long Beach Breast Cancer
Coalition
P.O. Box 844
Long Beach, NY 11561
Make check payable to: LBBCC
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| Date:__________mm/dd/yy |
| Name:______________________________________________ |
| Company (if applicable): ______________________________ |
| Address:____________________________________________ |
| City:_______________________________________________ |
| State:_____ZIP:________Phone:(____)___________________ |
| Fax: (____)___________________ |
| Email:___________________@_________________________ |
| I
would like to become a member - Fee $10 | Renewal: ___ New Member:
___ |
| Your
tax deductible membership donation for this year is greatly
appreciated.
___ I am interested in becoming more involved in Coalition
activities
___ I am unable to be active, but would like to receive Coalition
mailings
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