| *Date: _________________________________ | * Required information |
| *Name: _________________________________ | *Home Phone: ( )__________________________ |
| *Address: _______________________________ | Business Phone: ( )________________________ |
| *City: __________________________________ | *Country:___________________________________ |
| *State/Prov:______________________________ | *Zip Code/Postal:_____________________________ |
*Username on Living with Graves Disease Forums: (please print) _________________________________________
Where Did You Find Out About the Living with Graves Disease website?__________________________________________________
Donation Enclosed: ( ) $10 Other _____________
A suggested donation of $10 would help cover administration costs but a donation (Checks MUST ONLY be payable to "MediBoard Inc.")
in any amount would be appreciated.
___________________________________________________________________
PLEASE RETURN FORM TO:
| United States: | Canada + International: |
|
MediBoard Inc. 24 Dixwell Avenue, #118 New Haven, CT 06511 USA |
MediBoard Inc. P.O. Box 94074 Toronto, Ontario M4N 3R1 Canada |