Make Checks payable to MIC and Send To: |
Minuteman
Implant Club 251 South Street Foxboro, MA 02035-2707 Thank you for your support!! |
| ............................................................................................................................................................................................ *Yes, we/I want to join and support the Minuteman Implant Club. Here are our dues for one year. This entitles us to receive the newsletter and to vote at club meetings. Please print: Date: __________ Dues are $15.00 per year. I/We are signing up/renewing for ___ year(s) Your Title & name: _________________________________________________________________ Spouse/Partner name: ______________________________________________________________ Children names/DOB: ___________________________________________________________________________ Address:_____________________________________________ City:_____________________State: ____ Zipcode: _______ E-mail: ____________________________________________Telephone _______________V/ TDD_______________ Dues_________________ Donation:________________ Person who has implant:______________________ Permission to be listed in MIC member Directory Y/N The Minuteman Implant Club (MIC) |
This
can be printed out on your printer. Make as many copies as you want. We are working on a page link to pay your membership fee on your credit card, or to use your PayPal account with our Internet provider. |