Environmental Health Coalition Membership Form
(for printing)

To fax or mail in your membership or renewal to EHC, please print out this Web page and fill in appropriately. (fax and mailing address are at the bottom of this page)

Join Environmental Health Coalition, San Diego's most effective environmental justice advocate!

Personal Information:

First name:

Last name:

Street:

City:

State/province:

Zip code:

Phone #

E-Mail:

Yes! I want to join EHC's fight against toxic pollution. Enclosed is my contribution of:

 

_______  $15

_______  $100

_______  $25

_______  $200

_______  $40 *

_______ Other $_________
                                                                                    

Your Payment Information:

You are paying by (circle one): Check / money order / MasterCard / Visa

Name on credit card:

Signature:

Card No.

Expires:

Please mail (enclose check or credit card number) or fax (credit card only) your membership to:

EHC
401 Mile of Cars Way, Suite 310
National City, CA 91950
Fax (619) 474-1210

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