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DBSA
Confidential Membership with a year's subscription for monthly LIFE IN BALANCE
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Date_________________
Name_______________________________ Day Phone ( )_______________
Street_____________________________ Night Phone ( )_______________
City/State ______________________________ 9-Digit Zip_______________
Professional agency if applicable____________________________________
Indicate: ___New Membership ___Renewal ___Change of address
Bi-MONTHLY Life in Balance NEWSLETTERS FOR A YEAR:
___ Individual Membership $25.00
___ Family Membership $35.00
___ Professional Membership $50.00.
This includes 5 bi-monthly newsletters sent to 1 address.
___ Institutional membership $130.00.
This includes up to 15 bi-monthly newsletters sent to 1 address.
Print added name/address or query--
Check or money order payable to DBSA $_________________
Donation may be a gift membership, a $_________________
contribution in memory or in honor of an
individual, family or organization.
TOTAL Enclosed (Tax deductible) $
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Mail check or money order with this form to:
DBSA · P.O. Box 32531 · Detroit, MI 48232-0531
Allow four to six weeks for delivery to begin. Try a free issue of
Life in Balance by taking part in groups where newsletter is available
for newcomers only.