Membership Form

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Indiana Addictions Issues Coalition, 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)

	Indiana Addictions Issues Coalition, Inc.
Individual Membership Fees
	$10.00 Individual / Student
	$15.00 Family
	$30.00 Professional
	$100.00 Founding
Corporate Membership fees
	$100 Corporate
	$250 Silver
	$500 Gold
	$1000 Founding
	I do not wish to join at this time, but would like to make a contribution of $ .
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.

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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
Indiana Addictions Issues Coalition, Inc.

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Your contribution may be tax deductible!

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

1-800-555-MHAI

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