National Amputation Foundation About NAF Executive Board of Directors NAF News Programs & Services Donation Information Contact Us Links Tips

Paul Bernacchio, President
40 Church Street
Malverne, NY 11565
Phone: (516) 887-3600
Fax:     (516) 887-3667
E-mail: amps76@aol.com

If you would like to join our Foundation as an Honorary Member, your support would be very welcome. Membership dues help to keep our many programs active and viable. Please either print this page and complete the Honorary Membership Application or send your name and address along with a check for $25.00 membership dues to the address above.

NATIONAL AMPUTATION
FOUNDATION

Honorary Membership Application

 Date: __________ [ ] New Member [ ] Renewal

 I hereby make application for membership in
 the National Amputation Foundation.

 Name _______________________________________ 

 Address ____________________________________ 

 ____________________________________________ 

 Telephone __________________________________ 

 Date of Amputation _________________________ 

 Type of Amputation:
 Hand:    [ ] RIGHT    [ ] LEFT    [ ] BOTH
 Arm:     [ ] RIGHT    [ ] LEFT    [ ] BOTH
 Foot:    [ ] RIGHT    [ ] LEFT    [ ] BOTH
 Leg:     [ ] RIGHT    [ ] LEFT    [ ] BOTH

 Is amputation service connected?  [ ] YES

 [ ] MALE         [ ] FEMALE      AGE: ______ 

 [ ] I am NOT an amputee, but wish to become
 an Honorary Member in order to help.

Membership Fee:  $25