Honorary Membership Application
Date: __________ [ ] New Member [ ] Renewal
I hereby make application for membership in
the National Amputation Foundation.
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