Name: ________________________________________________________
Complete Mailing Address:
_______________________________________
__________
_____________
______________________________________________________________
______________________________________________________________
This Payment Form Is For:
&
nbsp; AMOUNT
Annual Membership Fees &n
bsp; ________
Other (Identify) ________
&nb
sp; TOTAL FEES (U.S.) ________
Telephone: (Office)____________________ (Home)____________________
E-mail: ____________________________________ FAX: __________________
Type of Credit Card (MasterCard
and VISA ONLY):
_______MasterCard or _______VISA
PLEASE: Large and legible printed numbers are very important !!!
CREDIT CARD NUMBER: _________________________________________
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TOTAL AMOUNT OF CHARGE (U.S. DOLLARS): _____________________
Print Name: ________________________________________________
Signature: _________________________________________________
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Date: __________________________
Mail or FAX to:
Daphne Koinis Mitchell, Ph.D., Assistant Professor (Research), Child and Family Psychiatry,
Brown Medical School/Rhode Island Hospital, Providence, Rhode Island, 02903 Vox: 401-793-8632, Fax: (401)-444-8742, DKoinisMitchell@Lifespan.org