Environmental
Health
Network
EHN [of California]
P.O. Box 1155
Larkspur, California, 94977-0074
Support and Information Line
(SAIL) 415.541.5075
A 501 (c) (3) non profit agency.
Membership / Donation Form

EHN is a small organization, staffed by volunteers who are dedicated individuals who also live and work with EI/MCS.
We distribute information at tabling events, and engage in advocacy on behalf of chemically and electromagnetically injured.
Unfortunately, we are not yet equipped to handle membership orders electronically.

EHN is a 501(c)(3) nonprofit organization.
Our federal tax ID number is 94-3072515.

When, publishing our newsletter, the first $18 of your membership is not tax deductible.
(As we are in hiatus, at this time, your entire donation is tax-deductible.)
When we again publish, any amount you contribute above that $18 will be tax deductible.

Please print when filling out the form. Thank you.

I want to join the Environmental Health Network (EHN) [of California]. Enclosed are my annual dues of:

   __$15 Low Income/Disability     __$25 Basic     __$50 Professional

I am pleased to make a tax-deductible donation $__________________


Please accept my contribution to your Annual Fund campaign $__________________


Enclosed is a grant of $______________ to help offset the expenses associated with MCS advocacy of board and/or advisory board members.


My name _____________________________________________________________________


Address ______________________________________________________________________


City/state/full ZIP ______________________________________________________________


Phone __________________________________________________________


E-mail ___________________________________________________________


Date ___________________________________________________________




Make the check payable to EHN (do NOT send cash), and mail the form to:

EHN, PO Box 1155, Larkspur, CA 94977-1155




GIFT SUBSCRIPTION

I want to make a donation of a gift membership to go to the person named below.

   __$15 Low Income/Disability     __$25 Basic     __$50 Professional

Recipient's name __________________________________________________________________


Address _________________________________________________________________________


City/state/full ZIP _________________________________________________________________


Phone ___________________________________________________________


E-mail ___________________________________________________________


My name ___________________________________________________________________________


Address ___________________________________________________________________________


City/state/full ZIP ___________________________________________________________________


Phone __________________________________________________________


E-mail ___________________________________________________________


Date _____________________________________________________________



Make the check payable to EHN (do NOT send cash), and mail the form to:

EHN, PO Box 1155, Larkspur, CA 94977-1155




TRIBUTE


In honor of _______________________________________________________________________.


In memory of _____________________________________________________________________.


Please accept my donation in the amount of $__________________.


Please notify: ___________________________________________________________________


Address ________________________________________________________________________


City/state/full ZIP ________________________________________________________________


Phone __________________________________________________________


E-mail ___________________________________________________________


My name ________________________________________________________________________


Address ________________________________________________________________________


City/state/full ZIP _______________________________________________________________


Phone __________________________________________________________


E-mail ___________________________________________________________Date ____________________________________

Make the check payable to EHN (do NOT send cash), and mail the form to:

EHN, PO Box 1155, Larkspur, CA 94977-1155



Top of form
Return to EHN's homepage -- new domain name is ehnca.org
http://ehnca.org

Return to Barb Wilkie's homepage
http://users.lmi.net/wilworks

Updated: 7/1/2010

The Environmental Health Network (EHN) [of California], Membership/Donation form.
The URL of this page is:
http://users.lmi.net/~wilworks/ehnmemor.htm