Membership includes subscriptions to the National Organization quarterly journal, HEARTBEAT, the bimonthly Chapter newsletter, NOVA-FAX, and MH insignia pins (one for individual membership and two for family memberships). Please make a print copy of this application, check the appropriate box below, complete the requested information, and mail this form along with your check made payable to Mended Hearts Chapter 200 to:

The Mended Hearts, Inc., Northern Virginia Chapter 200, PO Box 897, Annandale, VA 22003-0897

Please Print Legibly:

Last Name: _______________________________________________________________________

First Name: _________________________  Spouse's Name: ________________________________

Address, City, State, Zip: _____________________________________________________________

Phone:  (         ) _______ — _______________  e-mail address: ____________________________

Occupation: ________________________   Retired:     Yes       No       Date of Birth: _____________

Volunteer!  If you have some “spare” time help us help others fight heart disease. Volunteer!
I want to help by:   (   ) Visiting Patients  (   ) Office Help  (   ) Other Support Committees
(refer to our web site at www.mendedhearts200.info for information on the Chapter’s committees).

How did you learn about Mended Hearts?: ________________________________________________

___________________________________________________________________________________

(   )  I am not a heart patient but wish to support the work of Mended Hearts.
(   )  I am not prepared to join Mended Hearts but enclose a contribution of $___________.

Note: Mended Hearts Chapter 200 is a participant in the Combined Federal Campaign (Agency # 7624).

* Members may be victims of heart disease and/or other individuals who wish to assist in the purposes of this organization and have paid the required dues. Family memberships are encouraged. They include two or more members of an immediate family living at the same address. If applicable, include names and pertinent information for each family member on a separate sheet of paper. National membership is required for chapter affiliation – this application covers both.