1. Type of payment
I enclose a check, or money order, (USA) or traveler's check (Outside USA).

I donated by credit card using the Network for Good "Donate Now" button on the PPS website (USA only)**

I wired funds to the PPS bank account.** California Bank and Trust, Routing# 121002042, Acct# 1270018121.

2. Type of donation:
Membership, $36* suggested donation.

Membership with additional gift.

Membership plus Patients' Guide to Pemphigus - $46 suggested donation.

Membership, Patient Guide and additional gift.

A Gift

3. Total amount:
$____________________

This is in honor of:
_____________________

I wish to remain anonymous. Do not acknowledge me in any publication.

Membership/Donor Form*

NAME__________________________________________
Mr, Mrs, Ms, Dr, Other ________
Credentials ______________ (MD, PhD, etc.)

Spouse or partner ______________________________

ADDRESS _________________________ Apt#_____ CITY__________________________________________ STATE/PROVINCE________________________________ COUNTRY___________ ZIP/POSTAL CODE___________
PHONE (_____)___________________
EMAIL___________________________

Date of birth: __/___/___ (If membership is for a couple, please list patient’s birthday.)

Check interest: Pemphigus vulgaris Pemphigus foliaceous Paraneoplastic pemphigus Bullous (mucous membrane) pemphigoid Cicatricial pemphigoid Other:________

SIGNATURE (Required)____________________________
TODAY’S DATE___/____/_____ (Required)

Print this form, write clearly and mail completed form to:
The Pemphigus & Pemphigoid Society
15934 Hesperian Boulevard #122
San Lorenzo, CA 94580

If you have questions contact us.

Membership includes the quarterly news magazine, Recovery, access to the Members' section of the PPS website and discounts on PPS publications and events.

Remember our shopping partners send us a portion on most purchases you make online. It's easy! For details, click on the "Shopping" link on the PPS homepage. Donate that old car, truck, rv, trailer or boat to the PPS! Get a tax deduction and help fund PPS programs and services.

Thank you!

*A donation is not required to become a member of the PPS. Fill in any amount or check here for a free membership.

**If you donate online or wire funds, we won't know more than your name and the amount of your donation, so you must send us this form to recieve your membership benefits.