Massachusetts CFIDS / FM Association

Massachusetts CFIDS/FM Association

Donation Form

The Massachusetts CFIDS/FM Association is dedicated to supporting research and promoting medical and public education in, and advocacy and support services for patients with Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS) of Chronic Fatigue Syndrome (CFS), Fibromyalgia Syndrome (FMS) and Myalgic Encephalomyelitis (ME). Your tax-deductible donation will support our mission.

To send a donation to the Massachusetts CFIDS/FM Association, please complete the form below and click on the [Submit Form] Button.

I would like to:

Submit a contribution of $

Please complete the following form:

Date
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone Number
Fax Number
email address
Internet Web ddress

Please check the appropriate boxes: I am:

Patient Patient's Parent Family Member

Health Care Provider Other

Age
Patient's Name (if different from above)

Payment --Cheque Visa MasterCard

SECURITY NOTE: Please MAIL, FAX, or PHONE in the Credit Card information. Do not EMAIL your card information to us.

mail to:
Mass CFIDS/FM Association phone: (617) 471-5559

PO Box 690305

Quincy, MA 02269-0305

Please make all checks payable to the Mass CFIDS/FM Association

Please send comments to: Webmaster
Last Updated on: 01/02/2004

Patient	Patient's Parent	Family Member
Health Care Provider	Other