FIGHT AGAINST MALARIA INFECTION
MEMBERSHIP APPLICATION FORM (PLEASE USE BLOCK LETTERS)
Name: ______________________________________
Title: ______________________________________
Address: ______________________________________
______________________________________
Post Code: ______________________________________
Telephone: ______________________________________
Email: ______________________________________
I wish to become a Friend of the Vass Medical Foundation  (please tick box)
I enclose a cheque payable to 'Friends of The Vass Medical Foundation" for $____________ as my subscription for the current calendar year.
I would like to pay my subscription by standing order and have completed the Banker's Order form overleaf.
I would like to pay by Credit card and authorise you to debit my Visa(  ) Mastercard(  ) with the amount of $______________.
(note: $50 or £25 minimum)
Credit Card no _____________________________________________
Name on card  _____________________________________________
Signature  __________________________________
Card expiry date:  Day ___________  Month____________   Year_____________

Please return completed form(s) to:

The Friends of the Vass Medical Foundation, VASS FOUNDATION LTD.,
145 – 157 St. John Street, 2nd Floor,
London, EC1V 4PY.

www.vassfoundation.org
Close This Window