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 equipped to handle membership orders electronically.

EHN is a 501(c)(3) nonprofit organization.
Our federal tax ID number is 94-3072515.
The first $18 of your membership is not tax deductible, when The New Reactor is published. It is in abeyance until someone can take over or my health improves.
Any amount you contribute above that $18 is tax deductible.

Please print when filling out the form. Thank you.
Date:

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 ___________________________________________________________
 


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 ___________________________________________________________


In honor or memory of ___________________________________________,

please accept my donation in the amount of $______. New Reactor in abeyance.

Please send notice to_______________________________________________

Address _________________________________________________________

City/state/full ZIP ___________________________________________________

Phone __________________________________________________________

E-mail ___________________________________________________________

My name _________________________________________________________

Address _________________________________________________________

City/state/full ZIP ___________________________________________________

Phone __________________________________________________________

E-mail ___________________________________________________________

Enclosed, please find total dollar amount of $__________.  

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

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

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

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