MEMBERSHIP/DONATION FORM

By joining the Breast Cancer Network of Western New York, Inc., you will receive notification of educational programs, quality of life activities, social events and support groups. All donations and membership fees are tax deductible

Name___________________________________________

Address_________________________________________

Town___________________________________________

State____________________Zip Code____________

Phone (_____) _______________________________

E-mail Address____________________________________

We will not share your information with any third party.

_____ I would like to volunteer for BCNWNY.

_____Enclosed is my annual membership dues--$25 check payable to BCNWNY.

_____I would like to make a  donation of:

$_____ ( ) in honor of:________________________

(  ) in memory of: ____________________________

Mail to BCNWNY, Inc.,3297 Walden Ave., Depew, NY 14043

Breast

Cancer

Network of Western New York, Inc.                             

Print this form, complete and mail with your check  to the address listed below. 

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