Yes! I want to Help NAMI Pennsylvania With a Tax Deductible Contribution

NAME_______________________________________________________________________

ORGANIZATION or AFFILIATE (if applicable)_____________________________________

ADDRESS________________________________________________________

CITY_____________________________________________________________

STATE____________________ ZIP______________

PHONE (home) _____________________ (work) ____________________

E-MAIL_____________________________________

Payment Method:

• Check (enclose)
• Money Order (enclose)

• Visa
• Master Card

Account #____________________________ Exp. Date____________________

Card holder's Name ________________________________________________

Card holder's Signature______________________________________________

__ My company (or spouse's company) will match my gift, please contact me.
__ I would like to make a gift of stock to NAMI Pennsylvania. Please contact me.
__ I would like to include NAMI Pennsylvania in my will. Please contact me.

In the past, NAMI Pennsylvania has touched the lives of thousands of Pennsylvanians. None of it would have been possible without the support of our donors- public and private, large and small.

Please help us continue to make a difference in the lives and health of families and consumers in Pennsylvania.

I would like to target my gift to:
__ Providing eductaion through Family-to-Family, Peer-to-Peer and other education programs.
__ Support general fund operations and special projects

__ In Honor of (name) _____________________________________________________

__ In Memory of (name) ____________________________________________________

SAVE THE DATE- October 27- 31, 2004!

Return to: NAMI PA, 2149 North 2nd St., Harrisburg, PA.  17110
1-800-223-0500