Tarlov Cyst Disease Foundation

Membership and Donation Form
(This form is provided if you prefer to make your donation or membership payment by mail)

First and last name________________________________________________________

Address__________________________   E-mail address_________________________

City_____________________________   State_________________________________

Country__________________________   Zip__________________________________

YES! I wish to join the Tarlov Cyst Disease Foundation and benefit from timely information in the Foundation’s E-Note Updates and other communications.

____    Charter annual membership    (joined in 2007)    $25
____    Regular annual membership   (joined after 2007) $35


YES! I would like to further assist the Tarlov Cyst Disease Foundation as a donor or as a supporter at a higher level.

• Donor: Any amount less than $100
• Sponsor: $100-$499
• Patron: $500-$999
• Benefactor: $1000-up
  
  

Amount you wish to donate:   __________

Please note that each time you use your credit card online to donate or pay your membership fees, the Foundation is charged a 2.9 percent processing fee by PayPal. If you would like to help us avoid this charge and ensure that your full membership dues and/or donation goes to the Tarlov Cyst Disease Foundation, please consider sending your contribution via check to the address below. Please print this form if paying by check, and mail it to the address below.

Del Dutcher, Treasurer
Tarlov Cyst Disease Foundation
18212 N. 4020 Road
Bartlesville, OK 74006
Fax: (918) 333-4895

Membership fee total:     _____________

Donation amount total:   _____________

TOTAL:  _____________