PHYSICIANS FOR SOCIAL RESPONSIBILITY -- Pittsburgh

Yes, I want to join PSR-Pittsburgh (and national PSR).

Name ___ ___________________________________

Title

Address ____________________________________________________

City ____________________ State ____       Zip Code _______

Telephone ____________________     _____________________________

         Home                                        Work

Fax ____________________    E-mail ______________________

I would like to become a member in category checked below:

___ $ 125 Regular Member (practicing health professional with doctoral degree)

___ $   50 Associate Member (general public and other health professionals)

___ $   35 Retired Member

___ $   15 Student Member (first year membership free)

PSR-Pittsburgh is a not-for-profit organization.

The official registration statement and financial information of Physicians for SocialResponsibility-Pittsburgh may
be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania 800-732-0999.
Registration does not imply endorsement.


Name	___ ___________________________________
	Title

Address	____________________________________________________

City	____________________ State ____ Zip Code _______

Telephone	____________________ _____________________________
	Home Work

Fax	____________________ E-mail ______________________

___	$ 125	Regular Member (practicing health professional with doctoral degree)
___	$ 50	Associate Member (general public and other health professionals)
___	$ 35	Retired Member
___	$ 15	Student Member (first year membership free)