www.mdfwales.org.uk

Manic Depression Fellowship
Membership Application Form

Name:

Address:




Telephone:

Postcode:

Email:

Please indicate status: (tick box)

MD

Relative

Other

Student

Working

On Benefits

Retired

Other

How did you hear about MDF?


Annual UK Membership

Annual Overseas Membership

£15.00

£24.00

Individual

Individual

£30.00

£5.00

Unwaged

Organisation

£18.00

I enclose a donation of

Family

£

£25.00

I enclose membership of

Organisation

£

Total Amount enclosed

£250.00

Life Member

Signed:

Dated:

Please printout form and send with your membership fee or donation payable to:-
'Manic Depression Fellowship', 1 Palmyra Place, Newport, South Wales NP20 4EJ.