Don’t wish to give online? You can postal mail or fax in your membership, no problem!

Print out this form, fill it out and POSTAL MAIL or FAX in your MindFreedom annual membership, donation or renewal. (For a printable version of this form, click on the ‘printer icon’ that is in the upper right corner of this form — the middle icon.)

BY FAX: Print out, fill out with your Visa, MasterCard, Discover or American Express info, and fax it to (480) 287-8833.

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 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.


Name as it appears on credit card (please print): _____________________________________________

Signature:_______________________________________ Phone:(______)______________