YES, I WANT TO JOIN THE FIGHT
TO PROTECT TCOM
AND THE OSTEOPATHIC TRADITION IN TEXAS!
If you would like to help Keep TCOM DO, contact the TOMA Office at 800-444-8662, E-mail: lucyg@txosteo.org or FAX the form below.
PLEASE INDICATE ON FAX OR CHECK THAT IT IS FOR THE "TOMA WAR CHEST"
Mailing Address
Texas Osteopathic Medical Association
1415 Lavaca Street
Austin, TX 78701-1634
FAX credit card contributions to 512-708-1415
Please include all of the following information in your FAX:
One time contribution of $_______
Monthly contribution of $________
___ VISA ___ MASTERCARD ___ AMEX
Card Number: _____________________
Exp Date: _______
PRINT Name as it appears on card: ____________________________________
Authorized Signature:
____________________________________
