Please Print Name:__________________________________________

Street Address:_____________________________________________

City:_____________________________________________________

State:_____________ Zip:___________________  Email:_______________________________

Check: New Member Renewal                            Yes, I would like to Volunteer

Phone:( )__________________

Make your check payable to LFA, CT Chapter, Inc.

	$13.00 INDIVIDUAL MEMBERSHIP
									I AM A ______ LUPUS PATIENT ______ FRIEND ______ RELATIVE ______ OTHER
		$15.00 FAMILY MEMBERSHIP
			$35.00 SPONSOR MEMBERSHIP
				$50.00 PATRON MEMBERSHIP
					$100.00 ANGEL MEMBERSHIP
						$500.00 BENEFACTOR

ADDITIONAL DONATION FOR LUPUS RESEARCH__________________________

GOOD SAMARITAN
(CONTRIBUTION TO HELP WITH MAILING COSTS_______________________________