Your Email Address:*

First Name*: Last Name*:

Address:*

City: State: ZIP:*

Country:*

Home Telephone: Mobile Phone: Work Phone:

Employer: Occupation:

Peace Corps Country, Dates, Group:

Peace Corps Assignment:

Membership Category:

[ Individual (Friends of Fiji Only) $15.00] [ Couple (Friends of Fiji Only) $22.50] [ Individual (NPCA & Friends of Fiji) $50.00] [ Couple (NPCA & Friends of Fiji) $92.50]

If couple, name of second person:

Add $20 for overseas mail:

Optional Donations:

I wish to donate $ to Friends of Fiji for the following purpose:
[ Dan Cantor Fund ]
[ Peace Corps Partnership (development projects in Fiji)]
[ Friends of Fiji General Fund ]

DO NOT share my information with NPCA:

DO NOT share my info with local friends of Fiji groups:

Additional Comment: