Yes, we/I want to join and support the Minuteman Implant Club. Membership entitles us to receive the newsletter and to
vote at club meetings.
Date: May 9th, 2008
Dues are $15.00 per year. I/We are signing
up/renewing for:
Your Title & Name:
Spouse/Partner name:
Children names/DOB:
1)
2)
3)
4)
Address:
City:
State:
Zip:
E-mail:
Telephone:
Voice
TTD
Dues:
$
.00
Donation:
$
.00
Person who has implant:
Permission to be listed in MIC member Directory
Yes
No
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