Donation Form
Your gift to the Madison Institute of Medicine® will help ensure that our services are available at a reasonable cost to all in need and allow us to further develop these services for the benefit of all.

The Madison Institute of Medicine is a nonprofit 501(c)(3) organization. Your donation to the Madison Institute of Medicine is tax-deductible. To donate, please print this form, fill it out, and return it to us by fax or mail. Phone: 608-827-2470, Fax: 608-827-2479

Mail: Madison Institute of Medicine
7617 Mineral Point Road, Suite 300
Madison, WI 53717

Yes, I want to support the Madison Institute of Medicine with my gift of:

__ $25
__ $50
__ $100
__ $250
__ $500
__ Other $ ________

Please apply my donation to:

__Lithium Information Center
__Bipolar Disorders Treatment Information Center
__Obsessive Compulsive Information Center __Continuing Medical Education (CME)
__Where it is most needed

Additional information:

__ I do NOT want to be included on the annual list of donors. (Please check if you want your donation to remain anonymous.)

__ I would like to include the Madison Institute of Medicine in my will. Please send me the necessary information.

TOTAL DONATION$

Your information :
Name
Address
Address
City State
Country ZIP
Telephone
Method of Payment:
Check or money order made payable to:
Madison Institute of Medicine
MasterCard Visa
Acct # Exp. Date
Signature Date