Name         ________________________________________________________

Affiliation    _______________________________________________________

Position       _______________________________________________________

Address      _______________________________________________________

                   ________________________________________________________

                   ________________________________________________________

Telephone    _______________________________________________________

Fax              ________________________________________________________

e-mail           _______________________________________________________

Are you a National IFT member? ________________

Please mail application and check made payable to Dogwood IFT to:

Sharonda Eskridge
c/o Mother Murphy's Laboratories
PO Box 16846
Greensboro, NC 27416