NAMI Northern Illinois

P.O.Box 6971

Rockford, IL 61125

815-963-2470

Membership Enrollment Form

Today’s Date ______________

Please enroll me as a new member:   ________  or   Renew my membership:   ________

Name (s)               __________________________________________________________      

                       

Address               __________________________________________________________

                               __________________________________________________________

City/Zip                  __________________________________________________________

Phone                    home ______________ work_________________cell______________                      

Email                      __________________________________________________________

Individual/Family Membership $35.00 Annual Fee             _______

Advocate Membership $50.00 Annual Fee                          _______

Professional $75.00 Annual Fee                                            _______

Provider/Organization/Business $200.00 Annual Fee       _______

Open Door Membership $3.00 Annual Fee                         _______

for those whose funds are limited at the present time.

Renew my membership:                                                       _______

Donation:                                                                                   _______

Total:                                                                                          ________

 

Please make checks payable to

NAMI Norhtern Illinois