Printable Donation Form
Please Help! Join the MHA and make a difference TODAY!
Simply print this pledge form on your printer, fill it out completely, and mail it now with your Tax-Deductible Contribution to:
Mental
Health America
98 E. North Street
Greenfield, IN 46140
This information is for our internal use only. We will not share any information about you or your gift with anyone else. Providing your address enables us to thank you and periodically inform you about new events and other useful information.
| Please
print your information clearly below: | ||
| Full
Name: | ||
|
Street Address: | ||
| City: | ||
| State: | ||
| Zip: | ||
| Daytime
Phone: | ||
| Evening
Phone: | ||
| Social
Security Number: | ||
| E-mail
Address: | ||
| Your
signature: | ||
| Today's
Date: | ||
| Donation
Options | ||
|
Please
bill me for the total gift amount of: | $ | |
| or | ||
| Please
bill my credit card for the total gift amount of: | $ |
Card type: (VISA,MC,AMEX) |
|
Credit
Card Number: |
Expires: / | |
|
Cardholder's Signature: | ||
| or | ||
| Enclosed
find my check or money order for the total gift amount of: | $ | |
| Note: | Please make check or money order payable to "MHA" | |
Thank you for your support!