ICMJ Membership Application

YES!

I support ethical research methods in science and medicine. Please include me as a member of the International Coalition for Medical Justice, Inc., in the following category:

Individual $ 35
Student/Senior $ 20
Club/Association $100
Corporation $185
Educational $250
Other $_____

We gratefully accept donations in excess of the above categories.
Dues and contributions to 501(c)(3) corporations are tax-deductible. Checks are be made payable to ICMJ.

We regret that we are currently unable to receive dues payments by credit card.

Name__________________________________________ email_________________________

Address ________________________________________ fax __________________________

________________________________________

Contact Person ___________________________________

Telephone ______________________________________

Date: _____________________ Signed: _______________________________

ICMJ
763 Madison Rd.
Suite 206 1/2
Culpeper, VA 22701
540-829-9350
ICMJ@biosys.net
Deane Collie, Executive Director

NOTICE: The International Coalition for Medical Justice, Inc., is a nonstock, not-for-profit Virginia corporation that has applied to the IRS as a charitable organization under Section 501(c)(3) of the Internal Revenue Code. A copy of our financial report is available from the Virginia Dept of Agriculture, Bureau of Consumer Affairs, or from our office.

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