MichUHCAN Membership FormIndividual 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 |