Just print this form, fill it out, and mail - it's that easy!

 

Name:
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e-mail address:
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Mailing Address:
Street


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     Apt number
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     City/State/Zip
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Phone Number:
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Annual dues are $12.00 - No one will be denied membership due to inability to pay.

Please submit as soon as possible.....

Make your check payable to "CSGMV" and mail to:
     c/o Pam Fahy
     7111 Koenig Road
     Rome, NY 13440


Please tell us a little about yourself. Include such things as when you were diagnosed; was it easy or difficult to get a correct diagnosis; are there any other Celiacs in your family; any suggestions for what you'd like to see on the web site; etc. The information helps in our continuing efforts to reach out and offer the support people need. Thanks.

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(please attach additional pages if necessary)

{form last modified Summer 2002