Membership Form

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Depression and Bipolar Support Alliance, 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 Depressive and Manic-Depressive Association, Inc.
	$10.00 Individual Membership.
	$250.00 Associate Membership.
	$500.00 Corperate 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
DBSA C/O MHAI
1431 North Delaware street
Indianapolis, IN 46202
(317)-638-3501
1-800-555-MHAI
Your contribution may be tax deductible!

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