NAMI-WCI MEMORIAL/HONORARY DONATION FORM

You may give by telephone or by filling & printing this form out and mailing it with your check to the address below.

National Alliance on Mental Illness - West Central Indiana
P.O. Box 6232
Lafayette, Indiana 47903-6232
Phone: 765-423-6939 Fax: 765-423-6092

Name

Address

City/State/Zip

E-mail Address Phone

This gift is made in MEMORY / HONOR of

SEND NOTIFICATION OF THIS GIFT TO:

Name

Address

City/State/Zip

Please sign card:

If this gift is made in honor of a person or a special occasion, please indicate the occasion for your donation: Birthday Anniversary Graduation Other

GIFT AMOUNT:

Select Payment Type:

Cash
Check (made payable to NAMI-WCI)
Visa Mastercard Discover
Card#: Exp. Date (xx/xx): (NAMI-WCI will not release your personal information to anyone.)

Signature:_______________________________________________

My company has a Matching Gift Program. I will have either enclosed my employer form with this gift or will mail it shortly.
I would like NAMI-WCI to find out if my company has a Matching Gift Program (please fill out the following information).

Company/Location:

Print this form and mail or fax to NAMI-WCI at the above address.

Thank you for your generosity! You will receive a receipt for your gift shortly!

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