Print and fax to 480.945.9650

The Neurofibromatosis Association of Arizona is committed to meeting the needs of people challenged with NF by providing care, comfort, support, information, education, funding for research, and other resources for its treatment, prevention and eventual cure.

Registration Form

Please return by November 11, 2002 and make check payable to:

Neurofibromatosis Association of Arizona

4219 N. 62nd Street, Scottsdale, AZ 85251

Packages:

Platinum . . . .$5,000.00             Bronze . . . . . . . .$1,000.00

Gold . . . . . . . .$2,500.00             Event Sponsor . . . .$500.00

Silver . . . . . . .$1,250.00            Individual . . . . . . .$200.00         

Contribution            $ __________.____

Total               $ __________.____

Name/Organization_______________________________________

Address__________________________________________________

City State Zip_____________________________________________

Phone/Fax________________________________________________

Team/Individual___________________________________________

1) __________________________3)______________________________

2) __________________________4)______________________________

___Check Enclosed

CC# ___________________________________________Exp. Date ______

Circle One:MasterCard  Visa  American Express  Discover

NFAZ is a 501(3)(C) non-profit organization

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