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************* Membership Application *************


Name:    ____________________________________

Address: ____________________________________

         ____________________________________

Phone #: ____________________________________

E-Mail   ____________________________________


May we share your name with other patients and CFIDS & FM associations.

(Y,N)______

Would you like to volunteer some of your time to help The Connecticut
CFIDS & FM Association, Inc. continue it’s various programs.

(Y,N)______

Please print out this application and enclose it with a $25.00
donation for a one year membership.

Checks should be made payable to:
The Connecticut CFIDS & FM Association, Inc.

Mail To:

The Connecticut CFIDS & FM Association, Inc.
P.O. Box 3010
Milford, CT 06460


Renewal ______           New Member ______


Additional Donations:

$10 ______                Donations
                             Are
$25 ______                   Tax
                          Deductible
$50 ______

Other ______