Membership Form

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Name ___________________________________________________ Title ___________

Address ________________________________________________________________________________

Address ________________________________________________________________________________

City/State/Zip plus ________________________________________________________________________

Phone _______________________________________

E-mail address _________________________________

HEAL is a non-profit organization – Contributions are tax deductible

I would also like to contribute to HEAL as a...

___ Lifetime..$1000+      ___ Sponsor……..$100-$499       ___ Benefactor.….$500-$999  

___ Patron.…$50-$99    ___ Contributor….$25-$49           ___ Friend……....$10-$24                


Contributions are listed in The Human Ecologist            ___ Check here if anonymity preferred

Payment (U.S. funds only)

Check, Money Order or Credit Card (all U.S. funds only);

__VISA    __MasterCard    __American Express: 

Account #________________________________________________ Expiration  date _______________


Membership __________       Contribution ___________     Total amount____________ 

Mail to:
Human Ecology Action League, Inc. (HEAL), P.O. Box 509, Stockbridge, GA  30281.
Credit orders are accepted by phone.  Call 770-389-4519 (Monday – Wednesday)