Indiana NORML Membership Form

First Name _______________________ Last Name _______________________
Address _______________________    
Address _______________________    
City _______________________ State  ________  Zip _______________
E-mail _______________________    
Web _______________________ Phone __________________
Date _______________________    
Send to: Indiana NORML
New Membership Director
3601 N. Pennsylvania St.
Indianapolis, IN 46205

Circle your membership

$15.00 Student

$25.00 Single

$50.00 Bronze

$100.00 Silver

$500.00 Gold

$1000.00 Platinum

$2500.00 Diamond

Other $______________

I would like to Volunteer for
Circle as many as applies

Event Participation

Bill Watch

Lobbying Efforts

Membership Drives

Fund Raising

Telephone

No Thanks, I just want to be a member without volunteering my time.

If you would like to become a member by using a Credit Card via PayPal Click Here.