 |
|
Lupus Mall Walks! Don't want to register online? Click here to view/print a registration form. |
CENTRAL NY BRANCH NORTHEASTERN NY BRANCH WESTERN NY BRANCH
|
|
fax: (716) 835-7251 e-mail: info@lupusupstateny.org |
| You can print out this form and mail it with your check or fax it in using your charge card to the address at right. |
Lupus Alliance of
Upstate NY
3871 Harlem Road Cheektowaga, NY 14215 |
|
|
|
||
|
|
||
| Last Name | First Name | Title |
|
|
||
| Address | Town | County |
|
|
||
| City | State | Zip |
|
|
||
| Phone | ||
|
|
||
|
PLEASE ACCEPT MY DONATION OF $
|
||
|
|
||
|
Please check one:
|
Visa
|
|
| MasterCard | ||
| Discover | ||
|
|
||
|
Credit Card #
CVV# (3 digit code on back)
|
Expires: | |
|
|
||
|
Signature
|
Print Name | |