Membership/Contribution Form

Well-Mind Association of Greater Washington, Inc.

Please enroll me as a member. My check is enclosed (payable to WMAGW):

__Associate - $25 __Sponsor - $50 - $75

__Patron* - $100 or more $________(enter amount)

__I prefer to extend support as a Non-member Donor: $_______

Name: __________________________________________ Date: ____________

Address: _______________________________________________________________

(Street) (City, State, Zip)

*Please list my name, and up to 2 additional lines as indicated below, as a WMAGW Patron. I understand it will appear for 1 year on the Patrons List. If blank, we will use "Name, City, State" listed above.

_________________________________________

Please mail completed form to

WMAGW

18606 New Hampshire Avenue

Ashton, MD 20861-9789

Tel. (301) 774-6617 __*I prefer that my name not be included on the Patrons List