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FAIRFAX COUNTY ALLIANCE FOR HUMAN SERVICES
2017-2018 MEMBERSHIP REGISTRATION

DATE_____________________________________________________________

NAME____________________________________________________________

MAILING  ADDRESS
  ________________________________________________

__________________________________________________________________

PHONE (day)___________________(night)___________________E-MAIL___________________

Check one: _______   Renewal _______  New Member

Check one: I'm registering as an individual (   ) OR
                      I'm registering as an organization's representative (   ).

The organization I represent is: __________________________________________________________

_____ Please check here if we may list your organization as an Alliance member in our printed materials.

_____ I would like to get involved in the Alliance's work.  Please call me.

Please consider a contribution to advance the Alliance's work!

Enclosed: $ 5.00       Alliance Dues for 2017-2018
                   $ _____   Contribution
TOTAL:      $ ________

This form, along with a check for your TOTAL payable to Fairfax County Alliance for Human Services (or FC Alliance for Human Services), should be mailed to:

Fairfax County Alliance for Human Services
Roxanne Rice
4223 Willow Woods Drive
Annandale, VA  22003