The Minuteman Implant Club (MIC)

Credit Card Signup

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 11th, 2009

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  

Person who has implant:

Permission to be listed in MIC member Directory Yes No


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