





	pxeeurope@aol.com

The PseudoXanthoma Elasticum (PXE) Support Group

Membership Application

Registered Charity No. 1055465

The PXE Support Group
15 Mead Close
Marlow
Bucks.
SL7 1HR

We need your personal address details so that we can get back to you. Please complete all sections in full. Your application will not be accepted otherwise.

Title:

Surname: *

Firstnames: *

House & Street: *

Town: *

County: *

Post code: *

Home Phone: *

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Do you have a sight problem?

Is there any other information you'd like us to have? Are you applying on behalf of a minor or another, for example?

The subscription owed is £10 per addess. Please type the amount you will be posting here.

Subscription: £

Please make Cheques payable to:
The PXE Support Group (PiXiE)

If you wish to make a donation, we would be most grateful.

The Pseudoxanthoma Elasticum Support Group is a registered charity: No 1055465