Pneuma Life Membership Application
To apply for membership please complete the following form and make a donation.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
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Wisconsin
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State
Zip Code
Phone Number
*
E-mail
*
Would you like to be added to our email roster?
*
Yes
No
Disclaimer & Signature
I certify that my answers are true and complete to the best of my knowledge.
I understand that false or misleading information in my application may result in the termination or release of my membership.
I also understand that a portion of my membership will be donated to the Judy E. Brown Memorial Fund.
Signature
*
Date of Signature
*
/
Month
/
Day
Year
Date
My Products
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Individual Membership
$
25.00
$50 Donation
$
50.00
$75 Donation
$
75.00
$100 Donation
$
100.00
Custom Donation
Please adjust the quantity to reach the desired donation amount.
$
10.00
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Check / Money Order
I will send a Check or Money Order payable to: Pneuma Life Foundation | P. O. Box 248154 | Lyndhurst, Ohio 44124 | Contact: (216) 820-0122
$
Free
Cash App
I will send my donation via Cash App: $PLF1996
$
Free
Submit
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