Membership Application

• Individual/Family Membership
  $35.00 annual fee
  
  

• Professional Membership
  $50.00 annual fee

• Open Door Membership
  Individuals/families/consumers with limited income are invited
  to join NAMI at a reduced annual membership rate.
  Amount: $3.00
• VIP Provider/Organization
  $200.00 annual fee

ORGANIZATION__________________________________________________

NAMI PA AFFILIATE______________________________________________

ADDRESS________________________________________________________

CITY_____________________________________________________________

STATE____________________ ZIP______________

DAY PHONE (_____)__________________________

E-MAIL_____________________________________

Payment Method:

• Check (enclose)
• Money Order (enclose)

• Visa
• Master Card

Card#_______________________________________

Exp. Date____________________________________

Signature_____________________________________

Return this application to:

NAMI PA Dauphin
2149 North 2nd St.
Harrisburg, PA.  17110
1-800-233-0500

I/We understand that by joining NAMI PA Dauphin, our
membership dues will be shared with our local
affiliate, the state organization, and the national office.