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Mental Health America of Indiana

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

	The Mental Health America of Indiana.
	$25.00 Individual Membership
	100.00 Corporate Membership
	250.00 Corporate Membership
	1,000.00 Corporate Membership
	I would like to make an additional donation of $
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If you would like to fax this form the number is (317) 638-3540.

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Mental Health America of Indiana

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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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