Physicians for Social Responsibility
Sacramento Chapter

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Join/Donate/Annual Dinner Payment

YES! I want to participate in PSR's work
to protect human health and the environment.

Prefix:

Dr. Mr. Mrs. Ms. Miss

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Last Name:

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Home Phone:

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Work Phone:

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Dinner Guests:

Membership:
	Sponsoring Member (Physicians & other health professionals w/ doctoral degrees)	$125
	Supporting Member (Residents, Interns, Nurses, other health professionals, concerned citizens)	$50
	Retired Member	$35
	Student Member	$15
Donation Amount		$
Scholarship Fund		$
April 29, 2012 Scholarship Dinner Payment:
	Number of Adults ($30 per adult)
	Number of Students ($15 per student)
Number of vegetarian dinners (if applicable)

PSR/Sacramento is a 501(c)(3) non-profit organization. Membership payments and donations are tax-deductible. Dinner payments are not tax-deductible.

I will submit payment:

by sending a check to PSR Sacramento

with a secure credit card payment

PSR is the U.S. affiliate of International Physicians for the Prevention of Nuclear War, winner of the 1985 Nobel Peace Prize The Sacramento/Davis Area Chapter of Physicians for Social Responsibility 10 Dumfries Court Sacramento, CA 95831
916-955-6333	www.sacpsr.org	info@sacpsr.org