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National ME/FM Action Network Membership Application Form
613-829-6667
There is still much work to be done. Please help us help you by becoming a member!
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| Name Date Phone |
| Address City |
| Prov/State Postal/Zip Code Country |
| Email Website |
| New member , Renewal . I have ME/CFS , FMS . |
| I would like to volunteer my time , ideas , other |
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Annual Membership fee $ 25.00 *Tax receipt will be issued
(includes newsletter) for donations. |
| Quest Collection II $ 38.00 You can designate your |
| TEACH-ME $ 22.00 United Way donation to go to the |
| Legal Disability Manual $ 60.00 National ME/FM Action Network |
| CPP Guidelines $ 7.00 Charitable tax no.: |
| * Donation (BN) 89183 3642 RR0001 |
| Total |
| Payment: cheque ; Master Card ; Visa . Expiry date: |
| Card number: ∠∠∠∠ ∠∠∠∠ ∠∠∠∠ ∠∠∠∠ |
| Card holder (print): Signature: |
Cheques payable to: National ME/FM Action Network,
3836 Carling Ave., Nepean, ON K2K 2Y6, Canada |
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Medical Professionals, Lawyers & Support Group Leaders,
please complete appropriate sections. |
| Name Phone |
| Clinic/Firm Fax |
| Address City |
| Prov/State Postal/Zip Code Country |
| Email Website |
| Signature |
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Medical Professionals Only |
| I am a MD ; Other ; Qualifications Specialty |
| Do you diagnose ME/CFS ; FMS ? Do you treat ME/CFS ; FMS ? |
| How many patients have you treated that have ME/CFS ; FMS ? |
| May we refer patients to you? May we publish your name? |
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Legal Professionals Only |
| I am a lawyer ; other . |
| Do you handle legal matters for ME/CFS? FMS ? May we refer clients to you? |
| If so, may we publish your name? Will you give a free initial consultation? |
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Support Group Leaders Only |
| Organization |
| Number of people in group ME/CFS ; FMS . |