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Michigan Universal Health Care Access Network


MichUHCAN Membership Form

Individual dues: $15.00 per year. ($5.00 low income)
Organizational dues: $50.00 per year.
All donations cheerfully accepted.

Name:_______________________________________

Address:_____________________________________

_____________________________________________

City:_________________________________________

State: _______________ Zip:____________________

Phone:_______________________________________

E-mail address:________________________________

This is a (circle one): new membership renewal membership

(Snail) Mail to:

MichUHCAN
8846 Robindale
Detroit, MI 48239