Membership Form

Print this page

APS Industries, Inc. and Community Connections, Inc.

I would like my contribution to go towards Membership or Donation.

I would like my contribution to go to the following organization. (Check one below)

	APS Industries, Inc. and Community Connections, Inc.
	$25.00 Individual Membership
	$100.00 Corporate Membership
Please only select one at a time. If you wish to become a member or donate to more than one organization please send this form multiple times. Thank you.
My payment or donation is not included this time because I would like to request additional information on the above organization that I have selected.

Please enter all applicable information below

Your Name
Address
City
State
Zip Code
Phone #
E-mail
Organization
Payment amount
In memory of

Please mail this printed page to the address below.
If you would like to fax this form the number is (317) 638-3540.

Please make checks Payable to
APS Industries, Inc. and Community Connections, Inc.

Your contribution may be tax deductible!

Print this page

Mental Health America of Indiana
1431 North Delaware Street
Indianapolis, IN 46202
(317) 638-3501

1-800-555-MHAI

- Home - Donate Now - Become a Member - Contact us - User Agreement -