MHA-M Membership Application 2022
Thank you for your interest in joining us at MHA-M!
Name of Member
*
Prefix
First Name
Last Name
Name of Organization (If Organizational Member)
Alternative Representative Name (If Organizational Member)
Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
E-mail
*
What is your interest in issues related to mental health?
What type of Organization?
Unincorporated Organization
Corporation
Government Entity
For Profit Organization
Nonprofit Organization
Other
What type of Non-profit?
IRS 501c(3) charitable
Public/Governmental
Faith-Based
Other
Suggested Levels of Membership/Support
*
$25 - Individual Member
$35 - Family Member
$50 - Nonprofit Organization
$100 - Corporate Gift
$250 - Friend of MHA-M
$500 - Patron
$1,000 - Sponsor
$2,000 - Circle of Excellence
Other
How will you be paying?
*
Online
Check
Other
If paying online with your application, please select the following.
$25 - Individual Member
$35 - Family Member
$50 - Nonprofit Organization
$100 - Corporate Gift
$250 - Friend of MHA-M
$500 - Patron
$1,000 - Sponsor
$2,000 - Circle of Excellence
Other
I wish to make a donation.
$10
$25
$50
$100
$500
Other
Credit Card Charge
Add 2.90% + $0.30 credit card transaction fee.
Total
Payment
*
prev
next
( X )
USD
The total amount of your membership fee for MHA-M.
Credit Card or Debit Card
Please verify that you are human
*
Join MHA-M Today!
Should be Empty: