Indiana Council PAC Registration

Attendee Name

First

Last

Attendee Name

First

Last

Attendee Name

First

Last

Attendee Name

First

Last

Attendee Name

First

Last

Agency/Firm

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Total Number of Attendees From Your Organization

Please make checks payable to: Friends of Indiana Mental Health Centers Questions: Contact Denise Wade at: 317-684-3684 or dwade@indianacouncil.org.

Personal contributions are a great way to support your PAC. Feel free to use this form along with your personal contribution to support the public policy efforts of the mental health industry in Indiana.

This contribution is not tax deductible, however, it will go a long way to make sure our voice is heard at the Indiana Statehouse!