Membership - Donation

Please print this form and send it to us

with your check or credit card information Visa/MasterCard,

or      - click here -

to pay online

Name: ____________________________________________________________

Address: __________________________________________________________

City: _____________________________________________________________

State: ____________________________________________________________

Zip/Postcode: ______________________________________________________

Country (if not USA): ________________________________________________

Phone (home): ______________________________________________________

Phone (work): ______________________________________________________

Fax: ______________________________________________________________

E-mail: ____________________________________________________________

NOTE: Our mailing list is entirely confidential and is never rented nor sold. See Privacy Policy

Yes, I want to help stop VHL!

Amount of my donation: _____________________________ $ _______________

Payment for items checked on the enclosed publications list: $ _______________

or other: ___________________________________________$ _______________

Total payment: _____________________________________ $ _______________

My donation is q in honor of  /  q in memory of

___________________________________________________________________

Please send an acknowledgement card to:

___________________________________________________________________

___________________________________________________________________

*** Note: internet e-mail is not trustworthy enough to send credit card numbers without encryption.  Pay online by clicking here  or send this form by fax or paper mail, or phone us at 1-617-277-5667.   Thank you!

I am enclosing my payment, or charge it to my q Visa or q Mastercard

Card number: ______________________________________________________

Name as it appears on the card: _______________________________________

Expiration date: ____________________________________________________

VHL Family Alliance
US Non-profit corporation, Tax ID 04-3180414
2001 Beacon St, Suite 208, Boston, MA 02135-7787 USA
Tel: 1-617-277-5667; Fax: 1-858-712-8712