To join or contribute:

$25 per year per individual; $150 per year per family organization; or $200 per year per provider/professional organization.

We depend on your generous extra donations! You may pay by check or credit card.

Send completed form with payment to: 

VOR

5005 Newport Drive, Ste. 108

Rolling Meadows, IL 60008

847-253-6054 fax (for credit card payments)

Name: _____________________________________________________________

Address: ____________________________________________________________

City: _______________________________________________________________

State: __________________ Zip _________________________________________

Home Phone: ____________________ Work Phone: _________________________    

Fax: ____________________________ E-Mail: _____________________________

Family/Professional Organization Affiliation (if applicable): _____________________

If paying by credit card, please provide the following information:

Type of card:   ___ VISA  ___ MASTERCARD

Amount to charge to card:
___$1,000 ___$500 ___$250 ___$150 ___$50 ___$25   $_____ Other amount

_____ Master Card
_____ Visa

Card Number: ___________________________________

Expiration Date: __________________________________

Cardholder's Signature: ___________________________

THANK YOU FOR YOUR SUPPORT!!!

VOR * 836 S. Arlington Heights Rd., #351 * Elk Grove Village, Illinois * 60007

877-399-4VOR ph. * 847-258-5273 fax * tamie327@hotmail.com