Corporate Membership Application

(please type answers, print, and mail or fax this form)

Company Name: (as you wish it to appear in published materials)

Address:

City:

State: Zip:

Contact Person:

Title:

Telephone: ()

Fax: ()

E-mail:

Web Site: http://

Membership Level: $

• Gold: $1,000 or more
• Silver: $500
• Bronze: $300
• Basic:$100

Method of Payment:

Payment Enclosed Check #

Please make check payable to Alzheimer's Association, National Capital Area and mail to the address below, ATTN: Accounting.

Please Invoice

Credit Card Information:      Visa      Mastercard      American Express

Name of Cardholder: (as it appears on the credit card)

Account Number:                                      Expiration Date:
          

Signature: (please do not type; print and then sign in pen ink)

Date:

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Please provide us with a contact person for each of the following departments:

1. Community Relations:

   Telephone: ()

   Fax: ()

   E-mail:

2. Human Resources:

   Telephone: ()

   Fax: ()

   E-mail:

3. Marketing / Public Relations:

   Telephone: ()

   Fax: ()

   E-mail:

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Send all information to:

Alzheimer's Association, National Capital Area
11240 Waples Mill Road, Suite 402
Fairfax, VA 22030
(FAX) 703/359-4441

© 1997 - 2001 Alzheimer's Association, National Capital Area. All rights reserved.