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Yes! I want to join ICIHS' Partnership Program as a member of the (please check one):

 Centurion Society  $200
 Founders Circle  $100
 Patrons Club  $75
 Friends of ICIHS  $50
 Please accept my additional gift of $________ to further support the important work of ICIHS.
My check in the amount of $______ is enclosed. (Please make check payable to ICIHS)
Please charge my account $______________
Card Number:_________________________
Expiration Date:_________________________
Signature of Cardholder:_________________________
Please Print Name:_________________________
This is my mailing:
Full Name:_________________________
Street Address:_________________________
City, State, Zip:_________________________
Telephone Number:_________________________
Fax Number:_________________________
E-mail Address:_________________________
(ICIHS does not make its mailing list available for purchase)
Please allow 3-4 weeks for a confirmation receipt of your ICIHS partnership.

PLEASE NOTE: Effective August 15, 2001, we will begin doing business as the International Center for the Integration of Health and Spirituality (ICIHS). However, our legal name will remain National Institute for Healthcare Research (NIHR).

ICIHS is a 501(c)(3) non-profit organization. A portion of your partnership support may be tax deductible as allowed by law. Please contact your tax advisor for your individual circumstances and current tax laws.

A copy of our current financial statement is available upon request by contacting ICIHS, 6110 Executive Boulevard, Suite 908, Rockville, MD 20852, (301)984-7162. Documents and information submitted to the State of Maryland under the Maryland Charitable Solicitation Act are available from the Office of the MD Secretary of State, State House, Annapolis, MD 21401 for the cost of copying and postage.

Thank you!
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