Lou Gehrig Legacy Society Membership Registration Form

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YOUR CONTACT INFORMATION
*Name(s):
Date(s) of birth:
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GIFT INFORMATION
I/we have remembered in my estate plans:
The ALS Association's National Office A Local Chapter of The ALS Association Both the National Office and a local chapter
Chapter:	Please select a state Alabama Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Nebraska New Hampshire New Jersey New Mexico New York North Carolina Ohio Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Please select a chapter
I/we have included ALSA in my/our will or revocable trust I/we have named ALSA in an irrevocable trust or life-income arrangement I/we have made ALSA the beneficiary of...
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