NAMI San Diego - Membership Application

Let's work together to improve the quality of life for everyone affected
by mental illnesses in San Diego.

NAMI San Diego
Attn: Membership
P. O. Box 710761
San Diego CA 92171-0761


Name: _________________________________________________________________

Street: _______________________________________________________________

City/State/Zip: _______________________________________________________

Email: ________________________________________________________________

Phones:  Home: _______________________   Work: ________________________

         Cell: _______________________    Fax: ________________________

Send my newsletter via e-mail_____

Dues include membership in and newsletters from NAMI National and 
NAMI California.

_____ $40.00    Membership     New Member [ ]    Renewal [ ]

_____ $75.00    Professional Member

_____ $100.00   Organizational Member

_____ I am requesting scholarship help for my membership
      (contact the Membership Secretary at (619) 584-5564 x 105)

I would like to make an additional contribution of $_______________
(unless otherwise specified, the first $40 of any donation is considered
membership)

_____ Please send me information about other ways I can help.

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Payment by Check

Make check payable to NAMI San Diego
 
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Payment by Credit Card

[ ] Visa      [ ] MasterCard

Name as on Card: _________________________________________

Card Number: _____________________________________________

Exp. Date: _______/_______   Amount $_____________________

Signature: _______________________________________________
 
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Donations are Tax Deductible-Federal Tax ID #33-0122462