COMMUNITY SUPPORT ACT SUPPORTER



_____Please list our organization as a Community Support Act Supporter.

_____We would like to work on the state level to support Community 
     Choice Act.

_____ We can provide in-kind resources to support Community Choice Act.

_____ We can provide financial support for Community Choice Act.

_____ Please add us to the Community Choice Act Email* list for 
      updates.


Name of Organization:  _______________________________

Contact Person:  __________________________________

Address:   ___________________

City: ____________      State: _________     Zip: __________

Phone: (     ) ____________       Fax: (     )  _____________

TDD    (     ) ____________        *e-mail:   _______________

Our group is a national  ________ / state ________ / local ________

Date: ______________

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dbs_____   list_____    pkg____