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Acoustic Neuroma Association
600 Peachtree Parkway
Suite 108
Cumming, GA 30041
Phone: 770-205-8211
FAX: 770-205-0239

Membership/Donate


We are grateful for all gifts that help ANA provide information, education, research and support of acoustic neuroma patients and their families.

The Executive Board of ANA advises that names and addresses gathered here are used only to mail a quarterly newsletter, inform members about local support group meetings and send other official ANA mailings. Names are not used for any commercial purposes and the data is not sold. Member names are not shared with other members without first asking permission.

Your membership/donation entitles you to membership in ANA, and provides you with the following benefits:
  • Receipt of our quarterly newsletter, NOTES
  • Availability of patient information booklets on all aspects of acoustic neuroma pre- and post-treatment care. New members will be sent our initial free packet of information.
  • Information about our national symposium held every other year for acoustic neuroma patients, family members and medical professionals
  • Access to our network of support groups
  • Access to our website Member Section
In addition to these benefits, your membership helps support ANA in the following endeavors:
  • Promote, initiate and publish results of research on the effects of acoustic neuroma
  • Maintain an interactive website with the ANA Discussion Forum

This site is secure for credit card transactions.

Please complete the information in this form and press the "Submit" button at the bottom.
Note that items marked with an "*" are required fields.
For new users - a username and password are necessary to complete the form. Your username and password are required for the ANA Member Section. Please make sure your username and password are 5 characters or more using both numbers and letters.

Donation:
My Information:
*:
*:
*:
*:
*:
*:
:
*:
*:
Patient Type*:    Pre-treatment Patient
   Watch-and-Wait Patient
   Allied Health Care Professional
   Medical Professional
   Post-treatment Patient
   Family Member or Other
My Support of ANA:
  ANNUAL MEMBERSHIP DUES:
 
  USA Membership
$40
   International Membership $60
   Allied Health Care Professional $80
   Medical Professional Membership  $150
  AFFILIATE MEMBERSHIP DUES:
   Non-Profit Membership $100
   Commercial Membership $200

Membership Fee:
$

Please select a donation category and then enter the amount you wish to donate in the box to the right. Please enter your donation in whole dollars, with no decimal places or commas.
Category   Amount
  ANArchAngel $5,000 and above $
  ANAngel $2,500 - $4,999 $
  Grand Benefactor $1,000 - $2,499 $
  Benefactor $500 - $999 $
  ANA Patron $250 - $499 $
  ANA Donor $100 - $249 $
  ANA Friend $50 - $99 $
  Other   $
 
Total Dues and Donation Payment: $
My Payment:
  Please enter your Credit Card billing information.
  Credit Card Type*:
  Credit Card #*:
  Expiration Date*:
  Card Verification #*:   CVN
(On the back of your card find last 3 digits in the signature block area)

  Please enter the following information if it is different from "My Information" already entered above:
  Name as it appears on card:
  Street Address Line 1:
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:
  I wish this gift to remain anonymous.
  All donations are tax-deductible to the extent of the law. Donations received in excess of the Annual Membership Dues will be acknowledged by letter. Donations of $50 or more will be recognized in ANA Notes, our quarterly newsletter.
My Special Gift Information:
  MATCHING GIFT - My employer may match my donation.
(If possible, please enclose your employer's matching gift form.)

  Company Name:
  Street Address Line 1:
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:

 

  TRIBUTE GIFT - This donation is in    in Honor of      in Memory of
  Whom:
  Please notify (Name):
  Street Address Line 1::
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:

Acoustic Neuroma Association: Phone: 770-205-8211 | FAX: 770-205-0239
Membership
My Information:
  Username:*
  Password:* User Name and Password are required for Member Section.
  Retype Password:*
  First Name:*
  Last Name:*
  E-Mail Address:*
  Address Line 1*:
  Address Line 2:
  City*:
  State*:
  Province:
  Zip*:
  Phone Number*:
  Patient Type*:    Pre-treatment Patient
   Watch-and-Wait Patient
   Allied Health Care Professional
   Medical Professional
   Post-treatment Patient
   Family Member or Other
My Support of ANA:
  ANNUAL MEMBERSHIP DUES:
 
  USA Membership
$40
   International Membership $60
   Allied Health Care Professional $80
   Medical Professional Membership   $150
  AFFILIATE MEMBERSHIP DUES:
   Non-Profit Membership $100
   Commercial Membership $200
Membership Fee: $


DONATIONS:
Please select a donation category and then enter the amount you wish to donate in the box to the right.
Please enter your donation in whole dollars, with no decimal places or commas.
Category   Amount
  ANArchAngel $5,000 and above $
  ANAngel $2,500 - $4,999 $
  Grand Benefactor $1,000 - $2,499 $
  Benefactor $500 - $999 $
  ANA Patron $250 - $499 $
  ANA Donor $100 - $249 $
  ANA Friend $50 - $99 $
  Other   $
 
Total Dues and Donation Payment: $

 

My Payment:
  Please enter your Credit Card billing information.
  Credit Card Type*:
  Credit Card #*:
  Expiration Date*:
  Card Verification #*:   CVN
(On the back of your card find last 3 digits in the signature block area)

  Please enter the following information if it is different from "My Information" already entered above:
  Name as it appears on card:
  Street Address Line 1:
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:
 

 
  I wish this gift to remain anonymous.
  All donations are tax-deductible to the extent of the law. Donations received in excess of the Annual Membership Dues will be acknowledged by letter. Donations of $50 or more will be recognized in ANA Notes, our quarterly newsletter.
My Special Gift Information:
  MATCHING GIFT - My employer may match my donation.
(If possible, please enclose your employer's matching gift form.)

  Company Name:
  Street Address Line 1:
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:

 

  TRIBUTE GIFT - This donation is in    in Honor of      in Memory of
  Whom:
  Please notify (Name):
  Street Address Line 1::
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:

Acoustic Neuroma Association: Phone: 770-205-8211 | FAX: 770-205-0239
Donation:
My Information:
*:
*:
*:
*:
*:
*:
:
*:
*:
Patient Type*:    Pre-treatment Patient
   Watch-and-Wait Patient
   Allied Health Care Professional
   Medical Professional
   Post-treatment Patient
   Family Member or Other
My Support of ANA:

Please select a donation category and then enter the amount you wish to donate in the box to the right. Please enter your donation in whole dollars, with no decimal places or commas.
Category   Amount
  ANArchAngel $5,000 and above $
  ANAngel $2,500 - $4,999 $
  Grand Benefactor $1,000 - $2,499 $
  Benefactor $500 - $999 $
  ANA Patron $250 - $499 $
  ANA Donor $100 - $249 $
  ANA Friend $50 - $99 $
  Other   $
 
Total Dues and Donation Payment: $
My Payment:
  Please enter your Credit Card billing information.
  Credit Card Type*:
  Credit Card #*:
  Expiration Date*:
  Card Verification #*:   CVN
(On the back of your card find last 3 digits in the signature block area)

  Please enter the following information if it is different from "My Information" already entered above:
  Name as it appears on card:
  Street Address Line 1:
  Street Address Line 2:
  State:
  Zip/Postal Code:
  I wish this gift to remain anonymous.
  All donations are tax-deductible to the extent of the law. Donations received in excess of the Annual Membership Dues will be acknowledged by letter. Donations of $50 or more will be recognized in ANA Notes, our quarterly newsletter.
My Special Gift Information:
  MATCHING GIFT - My employer may match my donation.
(If possible, please enclose your employer's matching gift form.)

  Company Name:
  Street Address Line 1:
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:

 

  TRIBUTE GIFT - This donation is in    in Honor of      in Memory of
  Whom:
  Please notify (Name):
  Street Address Line 1::
  Street Address Line 2:
  City:
  State:
  Zip/Postal Code:

Acoustic Neuroma Association: Phone: 770-205-8211 | FAX: 770-205-0239