Paul Bernacchio, President

40 Church Street

Malverne, NY 11565

Phone: (516) 887-3600

Fax:     (516) 887-3667

E-mail: amps76@aol.com

If you would like to join our Foundation as an Honorary Member, your support would be very welcome. Membership dues help to keep our many programs active and viable. Please either print this page and complete the Honorary Membership Application or send your name and address along with a check for $25.00 membership dues to the address above.

NATIONAL AMPUTATION FOUNDATION Honorary Membership Application Date: __________ [ ] New Member [ ] Renewal I hereby make application for membership in the National Amputation Foundation. Name _______________________________________ Address ____________________________________ ____________________________________________ Telephone __________________________________ Date of Amputation _________________________ Type of Amputation: Hand: [ ] RIGHT [ ] LEFT [ ] BOTH Arm: [ ] RIGHT [ ] LEFT [ ] BOTH Foot: [ ] RIGHT [ ] LEFT [ ] BOTH Leg: [ ] RIGHT [ ] LEFT [ ] BOTH Is amputation service connected? [ ] YES [ ] MALE [ ] FEMALE AGE: ______ [ ] I am NOT an amputee, but wish to become an Honorary Member in order to help. Membership Fee: $25