North Carolina Psychoanalytic Foundation, Inc.

MEMBERSHIP CONTRIBUTION FORM

My Contact Information:
Name (Mr./Ms./Dr./Other______) __________________________________________
Degree__________ Occupation ____________________________________________
Street Address _________________________________________________________
City, State, Zip _________________________________________________________
Home Phone _______________ Work Phone _______________ Fax _______________
Email _________________________________________________________________

Membership Levels (check one category):

Benefactor

$1,000

Supporting Member

$150-$249

Patron

$500-$999

Contributing Member

$50-$149

Sustaining Member

$250-$499

Student Member

$30 (First Year Free)

Please Check All That Apply:

Please enroll me as a member. My tax-deductible contribution of $_____ is enclosed.
My/my spouse's employer will match my contribution. (Please include matching gift slip.)
I would like to make my contribution in honor/memory of _________________________
     Please send an acknowledgment to: (name)____________________________________
     (address) ________________________________________________________________
I am interested in volunteering. Please call me with information.
Please add me to the NCPF mailing list. (You need not be a member to be on our mailing list.)

Payment Method:
Enclosed is a check payable to the NC Psychoanalytic Foundation, Inc.
Please bill my: ( ) MasterCard           ( ) VISA
Name (as it appears on card): ____________________________________________
Total Amount: $______ Card #:_______________________ Exp.Date:_______
Zip Code (of credit card billing address): _____________________________________
Signature (credit card authorization): _______________________________________


Please return payment with this form to the North Carolina Psychoanalytic Foundation
Thank You!

901 Paverstone Drive, Suite 11 · Raleigh, NC 27615 · (919) 847-2323 · info@ncpsychoanalysis.org · www.ncpsychoanalysis.org