ACCHOS MEMBERSHIP

Please print this form and fill-in the details requested. Then, mail it to:
ACCHOS, Inc.
1009 Bay Ridge Avenue PMB 108,
Annapolis, MD 21403,
U.S.A.


My chosen ACCHOS Membership level is (please tick one):

	Grand Benefactor		$2,000
	Benefactor		$1,000
	Patron		$500
	Champion		$350
	Supporter		$250
	Sponsor		$100
	Contributor		$75
	Regular		$48
	Basic		$38

I wish to make an additional gift of: $______________


I enclose a check for: $________________________


My name and contact details are:

Name:
Address:
City:
State / Country:
Zip / Post Code:
E-mail:
Telephone: