INSTRUCTIONS: Please print this page, fill it out and mail it via regular US mail. Section A must be filled out completely for membership. Please fill out section B in order to be included in the directory. Your signature must be included in Section B. By not filling out Section B, you are choosing not to be listed in the directory.

NAME:    __________________________________________________
ADDRESS: __________________________________________________
         __________________________________________________
         (city)         (state)         (zip)

PHONE:   (________)________________________________________

I understand that NEO Visions publishes a monthly newsletter and a confidential membership directory for the use of members only. I further understand that all efforts are made by the Board of Directors to protect my privacy. Therefore, if I choose to be entered in any NEO Visions publication, I understand that neither the organization nor it's board of directors may be held liable for the actions of any individuals who might violate my privacy.

Print Directory Name: _____________________________________
Address:              _____________________________________
Phone:  _______________________  Birthday: Mo_____/Day_____
Email:  _______________________  Fax: _____________________

Signature: ________________________________________________