Mental Health Association in Alaska

Membership Renewal/Application

Please print out and fill in the requested information, then mail in with payment.

Personal Data

Name:                                                   

Title:    Mr.      Ms.      Mrs.      Dr.      Other (please specify)                           

Phone:                          

Street:                                                   

City/State:                          Zip Code:                         

Memberships (mark one):

   Student/Senior: $10

   Sustaining: $25

   Contributing: $50 to $100

   Patron: $100 to $500

   Corporate: $1000 and up

Information (mark all that apply)

   I would like more information about the Association

   I would be willing to devote time to the efforts of the association

Payment

Check or Money Order number:                          

This edition revised August of 1998.