Madness in the Streets Mail/Fax Order Form

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ORDER FORM: Madness in the Streets
(Print this form to MAIL or FAX your order.)

We at the Treatment Advocacy Center believe Madness in the Streets is mandatory reading for citizens who must still ask why thousands of individuals who clearly suffer from brain diseases go without care. For them and for those who ask "How can we stop this neglect?" the Treatment Advocacy Center is proud to republish Madness in the Streets in paperback form so that this valuable tool continues to remain available. Thank you for your order - and for your interest in this important issue.

TO ORDER BY FAX: Print out and complete this form with your credit card information and fax to 703 294 6010. If you prefer, you may call us with the credit card number at 703 294 6001.
TO ORDER BY MAIL: Print out and complete this form with your credit card information or enclose a check. Mail to:

Treatment Advocacy Center
ATTN: Publication order
200 North Glebe Road, Suite 730
Arlington, VA 22203

BOOK ORDER AND OPTIONAL DONATION

c In addition to my book order, I would also like to make a donation to TAC*. My donation is (circle one) in honor of/in memory of: _________________________________. [These gifts will be recognized in our quarterly newsletter, Catalyst.]

c No thanks, I do not wish to make a donation now.

Madness in the Streets ISBN 0-9679939-0-3 Quantity ordered		Price (includes shipping/handling)	Total for book order		Donation amount, if any*		New total
______________	x	$19.95	$_________	+	$_________	=	$_________
*The Treatment Advocacy Center is a nonprofit 501(c)(3) organization. Gifts are tax-deductible to the extent allowed by law. The Treatment Advocacy Center does not accept funding from pharmaceutical companies or entities involved in the sale, marketing or distribution of such products.

PAYMENT INFORMATION

Circle one: Visa - MasterCard - American Express - check [Check enclosed in the amount of $ _______________]
Credit card number:	Expiration date:
Signature:

BILLING INFORMATION

Name (on card)_______________________________________

Address_____________________________________________

City/State/Zip________________________________________

Telephone___________________________________________

E-mail______________________________________________

SHIPPING INFORMATION (if different)

Name______________________________________________

Address____________________________________________

City/State/Zip_______________________________________

Telephone__________________________________________

E-mail_____________________________________________

c Please also add me to your mailing list for your free quarterly newsletter, Catalyst (circle which address: billing/shipping).
c Please also add me to your email list for your free weekly email newsletter, ENews (circle which address: billing/shipping).

Treatment Advocacy Center

The contents of TAC's website are copyrighted by the Treatment Advocacy Center unless otherwise indicated. All rights reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes only, if correct attribution is made. TAC is an I.R.C. � 501(c)(3) tax-exempt corporation. Donations are appreciated and are eligible for the charitable contribution deduction under the provisions of I.R.C. � 170. Please note that TAC does not accept funding from pharmaceutical companies or entities involved in the sale, marketing, or distribution of such products.

Treatment Advocacy Center (TAC)
200 N. Glebe Road, Suite 730, Arlington, VA 22203
703 294 6001/6002 (phone) 703 294 6010 (fax) [email protected] (email)