Flower Essence Society
On-Line Gift Membership Application

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Please enter your billing information:

Title: (Dr,. etc.)
First Name:
Middle Name:
Last Name:
License: (DC, MD, etc.)
Organization:
Address:
City:
State/Province: (Required if you're in the USA or Canada)
Postal Code:
Country:
Telephone:
Fax:
Email:


Please enter information for the person receiving the Gift:

Membership is in the name of an Individual Organization or company

Title: (Dr,. etc.)
First Name:
Middle Name:
Last Name:
License: (DC, MD, etc.)
Organization:
Address:
City:
State/Province: (Required if you're in the USA or Canada)
Postal Code:
Country:
Telephone:
Fax:
Email:


Would you like the person receiving the gift,
be sent an email message?
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(Email address required for person receiving gift)



Description of gift recipient's health
practice and use of flower essences, if known: 



Message for gift notice:




Please enroll for membership as indicated below:
Flower Individual - $25 per year: basic level of support.
Bouquet Organizational - $50 per year: for group and commercial memberships.
Garden Supporting - $100 per year: assisting education & research.
Garden Angel Lifetime - $500: a lifelong association with our work.


Total amount to be charged: $

Card Number: CCV: (No spaces or dashes)
Expiration:
Cardholder Name:



 


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P.O. Box 459, Nevada City, CA  95959
800-736-9222 (US & Canada)
tel: 530-265-9163    fax: 530-265-0584

E-mail: mail@flowersociety.org

Copyright © 1998-2008 by the Flower Essence Society.
All rights reserved.

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