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Ride with MIND Car Tag

mind_center_car_tag_nolines.jpg

Support Alzheimer’s research and care in Mississippi with a MIND Center distinctive license plate.

To purchase a tag, please complete the form below.

You can also help by making a donation to The MIND Center Car Tag Fund. Donations made to this fund will provide tags to those in Mississippi affected by Alzheimer's. We hope you will consider supporting and encouraging others to support this fund so we can reach our goal.

RIDE with MIND



* = Required Fields

First Name* 
Last Name* 
Street Address* 
City* 
State*
Zip Code* -  
Phone Number*() -    
Email Address* 
County of Residence* 
Current Tag Number* 
Referred By:*
If Referred By an Event, please enter the event name here:
If Referred By a MIND Center Employee, please enter their name here:
If Referred By Other, please enter here:
Total Amount
Credit Card Info*
*
*
Credit Card Expiration Date*
*
(Located on the back of the card)