(PRINT THIS FORM AND MAIL)
MOEBIUS 'WARRIORS' MEMBERSHIP FORM

DATE________
PLEASE INDICATE ITEMS YOU ARE REQUESTING:

_______MOEBIUS 'WARRIOR' MEMBERSHIP CARD   [REQUEST VIA EMAIL]
                    (Reserved for individuals with Moebius Syndrome please.)  

_______MOEBIUS 'WARRIOR' SUPPORT MEMBER CARD    [REQUEST VIA EMAIL]
                    (Family, friends and other individuals or groups are invited.)
(  If you elect to go with the picture version......Don't forget to send the picture.......)

ON THE LINE BELOW, ENTER THE NAME OF THE MEMBER  OR SUPPORT MEMBER, AS IT SHOULD APPEAR ON THE MEMBERSHIP CARD OR CERTIFICATE.

(HERE)____________________________________________________

IF YOU ARE REQUESTING THE SUPPORT MEMBERSHIP , PLEASE INDICATE THE NAME OF THE MOEBIUS 'WARRIOR' YOU ARE SUPPORTING.  THIS NAME WILL APPEAR IN THE SPACE NAMED....."MY SPECIAL 'WARRIOR'..... ON THE SUPPORT CARD.

ENTER SPECIAL 'WARRIOR' NAME HERE__________________________________
ENTER YOUR RELATIONSHIP  IF YOU WANT IT TO APPEAR ON THE CARD OR CERTIFICATE__________________________________
   
THE ITEMS CHOSEN WILL BE SENT TO:

NAME_____________________________________________________

ADDRESS__________________________________________________

CITY____________________________STATE________POSTAL CODE___________________

COUNTRY________________________

MAIL THIS FORM TO
MOEBIUS1.ORG
W6340 CYPRESS ROAD
NESHKORO, WI     54960
USA