This survey is being done as part of a Master Program research project by Annette Bentley, a graduate student a Louisiana State University.
For further information contact the National Headquarters at the address shown below
American Celiac Society - Dietary Support
Coalition
P.O. Box 23455, New Orleans, LA 70183
U.S.A. (504)737-3293 E-mail: americanceliacsociety@yahoo.com
Please sign me up as a member
Enclosed is my annual tax
deductible membership fee of $30_____
Internatrional $40_____
Medical Professional $50_____
Company's $100_____
Enclosed is an additional gift of___________
Total amount enclosed ___________
ADDRESS_______________________________________________________________________
CITY _____________________________ STATE________________ ZIP CODE_____________
HOME PHONE_________ WORK PHONE___________E-MAIL ________________
SPOUSE NAME _________SEX [ ]Male [ ]Female BIRTH DATE ___AGE DIAGNOSED___
"American Celiac Society" Dietary Support Coalition