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: |
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
our application