Professional Memberships ($50)

Professional Memberships ($50)

I want to receive and other information from the Foundation.

I want to serve as a resource for the Foundation in my field or specialty. (If you want to be available to patients, please send a resume, brochure of your practice, and/or letter about your background to the Executive Director.)

Please send me __________ additional VPF brochures.


Name

Address

City / State or Province / Zip or Postal Code

Country

Telephone Number (Work)

Best times to call

E-mail Address

Field (Medical doctor, physical therapist, scientist, psychologist, etc.)

How did you hear about the Foundation?


Please print out a copy of this form and mail with
your fee of $50 plus international postage, if any, to:

The VP Foundation
Post Office Box 755
Graham, NC 27253
USA

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