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Please use this form to (1) send dues payments ($25 US from those who can afford it, or some amount from those who cannot); (2) request the IPCNSR Newsletter; (3) give our members information about yourself.

Name ____________________________

Address ___________________________

___________________________

Phone______________________ E-Mail address_________________________

With what pastoral care organization(s) are you affiliated

__________________________________________

Amount of dues payment ____________

Would you like to receive a Ribbon of Promise? ____________

Would you prefer to receive a hard copy of the newsletter or read it on the IPCNSR Web Page? ____________

Information about you, your activities and interests

____________________________________________________

Return completed form to:

     Lerrill White, Treasurer
     418 Mill Pl. Ct
     Sugar Land, TX, 77478
     USA

     Mike Cordner
     P. O. Box 1542
     Williston, VT 05495