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Please print out this form, fill it out, and mail
to:
Tourette Syndrome Association of New Jersey, Inc
50
Division Street, Suite
205 ,
Somerville, NJ 08876
Make checks payable to TSA, Inc.
Name:_____________________________________________
Address:___________________________________________
__________________________________________________
State:_________ Zip:______________________
Phone: | (Day) (_______)_____________________
(Night) (_______)_____________________ |
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I would like to become a member of the Tourette Syndrome Association
and receive TSANJ's newsletters, meeting invitations
and all future announcements. Enclosed is my tax
deductiable check made payable to TSA, Inc. |
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I am renewing my membership in TSANJ, Inc. |
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$45 Member ($33 goes to National TSA and $12 is returned to TSANJ
for family support, education and advocacy programs
in New Jersey.) You will receive all National and
New Jersey newsletters. |
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$100 Contributing Member. |
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$250 Sustaining Member. |
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I cannot afford $45 dues. Enclosed is a $________
donation to TSANJ. Please count me as a member. |
I am interested in Tourette Syndrome as a --
Patient;
Parent;
Teacher;
Physician;
Other (please specify)
_________________________________________ |
