National Alliance on Mental Illness       

Illinois' Voice on Mental Illness - NAMI Illinois


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Renewal/Addition
Address Change
Dues Worksheet

 

 

 

 

 

 

               

National Alliance on Mental Illness

Affiliate Renewal/Add Form

Affiliate #:                                                                  Affiliate Name:

Name of person completing form:                                Daytime Phone #: (        )

Date:     /      /                                                           Date:     /     /

{ Addition                                                                  { Addition

{ Renewal                                                                   { Renewal

NAMI ID#                                                                   NAMI ID #

Prefix                                                                       Prefix

First Name                                                               First Name

Last Name                                                                Last Name

Suffix                                                                       Suffix

Address 1                                                                 Address 1

Address 2                                                                 Address 2

City                                                                         City

State                                                                       State

Zip Code                                                                  Zip Code

Telephone                                                                Telephone

Spouse                                                                    Spouse

Exp. Date                                                                Exp. Date

Relation to Consumer (Please Check One)         Relation to Consumer 

{ Adult Child  { Consumer                                   { Adult Child  { Consumer

{ Friend  { Parent w/Child (under 18)                  {Friend {Parent w/Child under 18

{ Sibling       { Parent of Adult                             { Sibling   { Parent of Adult

{ Spouse      { Professional                                  { Spouse   { Professional

Ethnicity (Please Check One)                             Ethnicity (Please Check One)

{ African American { Asian                                  { African American { Asian

{ Hispanic       { Native American                         {Hispanic {Native American

{ White                 { Other                                   { White                 { Other

 

Please return this form to your State Office for membership processing.

Note: All membership addition or renewal paperwork should be accompanied by dues for both your State and NAMI.

 

Mail to:

NAMI Illinois

218 West Lawrence

Springfield, Illinois 62704