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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 |
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fax: (716) 835-7251 e-mail: info@lupusupstateny.org |
| You can print out a copy of this form and mail it with your payment or fax it in using your charge card to: |
Lupus Alliance of
Upstate New York 3871 Harlem Road Cheektowaga, NY 14215 |
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YEARLY DUES
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Single Member $18
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Family Member $25
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Patron $50
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Donor $75
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Sponsor $100
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Business or Organization $150
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| Please check one: | Visa | |
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| Discover | ||
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| Credit Card # CVV# (3 digit code on back of card) |
Expires: | |
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| Signature | Print Name | |
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RENEWALS DUE JAN. 1 (CHECK ONE)
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Renewal
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New Member
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MEMBERSHIP INCLUDES
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