MindFreedom Lane County Normathon - Skit for YouTube
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Postal mail or fax form to join/donate.
BY FAX: Print out, fill out with your Visa, MasterCard, Discover or American Express info, and fax it to (541) 345-3737.
BY POSTAL MAIL: Print out, fill out, include check, money order or credit card information, and postal mail to:
MindFreedom International (MFI); PO Box 11284; Eugene, OR 97440 USA
(Or e-mail office@mindfreedom.org with your postal address and request a membership sign-up packet.)
Donation enclosed (circle one): $1000 $500 $100 $75 $50 $35 (regular membership) $20 (low income) other: $_______
Group name (if any -- please print): ______________________________________
Name (please print):______________________________________________________
Address (1st line):_________________________________________________________
Address (2nd line):________________________________________________________City:_____________________________________ State/Province:__________________
Postal Code:_____________________ Country:_________________________________
Phone (optional): day: (_____)_______________ evening: (______)_________________
E-Mail/Web site (if any):_____________________________________________________
I want to charge my contribution (circle one):
VISA MasterCard Discover American Express
Or: ___ Check or money order is enclosed made out to MFI.
Card#:______________________________________________Expiration______________
Name as it appears on credit card (please print): _____________________________________________
Signature:_______________________________________ Phone:(______)______________
