 |
Membership Form |
| Date __________ | New ____ Renew ____ |
Name __________________________________________________ Chapter # _____________
Address ______________________________________________________________________
City/State/Zip __________________________________________________________________
Phone ( _____ ) _______________________ E-mail address ____________________________
Current employment status
| _____ Not employed for pay _____ Employed part time outside home |
____ Employed part time at home ____ Employed full time |
Current and/or former occupation __________________________________________________
I heard about Mothers & More from ________________________________________________
Please tell me about
| _____ How to start a chapter in my area | ____ Volunteer opportunities at the national level |
Membership fees (in U.S. funds)
_____ One-year membership (United States) $45
_____ One-year membership (International) $55
_____ Here’s my tax-deductible donation of $__________
to help with support and advocacy work.
_____ Send a gift membership (additional $45 or $55 enclosed)
to the person named below:
Recipient’s name _____________________________________Address ____________________________________________
City/State/Zip ________________________________________
Total remitted $________
Method of payment
____ MasterCard ____ Visa Name on card ________________________________ Card number _________________________________ Exp. date (m/y) _______________________________ Signature ____________________________________ |
____ Check, payable to Mothers & More |
Mail to: Mothers & More, P.O. Box 31, Elmhurst, IL 60126. Credit card orders only may fax to: (630) 941-3551. Questions? Contact the Mothers & More National Office at (630) 941-3553, or at nationaloffice@mothersandmore.org.