Scheduled Donation

 

YES! I want to help MIRA meet the ongoing challenge of funding brain research through a monthly donation of:

 

 

 

 

 

 

 $15

 $25

 $50

Other $_____________

 

I understand that I may discontinue my contribution at anytime if my financial circumstances change by contacting the MIRA offices or by email at donations@miraresearch.org.

 

 Credit Card (Visa, MasterCard, American Express)

 

Credit Card Number:

 

Expiration Date:

 

 

Signature:

 

 

Date Signed:

 

 

Contact Information:

 

Name:

 

 

 

Address:

 

 

 

 

 

Phone:

 

 

(         )

 

Comments:

 

 

 

 

Please Mail or Fax this order to:

The Mental Illness Research Association

1750 South Telegraph Road, Suite 103

Bloomfield Hills, MI 48302

800-896-6472 (Voice)  248-338-1599 (Fax)

email: donations@miraresearch.org

http://www.miraresearch.org