NAMI Clarion Membership Application

• Individual/Family Membership
  $23.00 annual fee
  
  

• Professional Membership
  $50.00 annual fee

• Open Door Membership
  Individuals/families/consumers with limited income are invited
  to join NAMI at a reduced annual membership rate.
  Amount: $3.00
• VIP Provider/Organization
  $200.00 annual fee

ORGANIZATION (if applicable)______________________________________

ADDRESS________________________________________________________

CITY_____________________________________________________________

STATE____________________ ZIP______________

DAY PHONE (_____)__________________________

E-MAIL_____________________________________

Payment Method:

• Check (enclose)
• Money Order (enclose)

• Visa
• Master Card

Card#_______________________________________

Exp. Date____________________________________

Signature_____________________________________

Return this application to:

Sharon Bowser
NAMI PA Clarion County  
RR 1  Box 256
Rimersburg, PA  16248
or
email E-mail Joan Beichner at  jbeichner@usachoice.net

I/We understand that by joining NAMI, our membership dues will
be shared with our local affiliate, the state organization, and the national office.