MICHIGAN POLIO NETWORK, INC

You may print out this page and mail it along with a check or money order payable to:
Michigan Polio Network, Inc.

Mail to: Michigan Polio Network, Inc.
1156 Avon Manor Road
Rochester Hills, MI 48307-5415
MICHIGAN RESIDENCY NOT REQUIRED FOR MEMBERSHIP
YOU DO NOT HAVE TO BE A POLIO SURVIVOR TO JOIN OUR NETWORK

Our membership fees are as follows:
One year - $15.00          Five Years - $65.00          Lifetime Membership - $150.00
Your membership includes a quarterly newsletter, use of our library, voting privileges as well as the networking and support from our membership.   Join today!

                                                 
Name                                                                                                                                            
Address                                                                                                                                        
City                                                                   State                                        Zip                   
e-mail address________________________________________________________________
(please print legibly)                                                     Polio Survivor? (yes / no)

Choose one type of membership :
One Year  $15.00          Five Year - $65.00         Lifetime Membership - $150.00

If you also wish to make a contribution to support the work of the Michigan Polio Network, Inc. designate your contribution amount enclosed $                       .  Thank You.

Change of Address Form

In order to continue receiving your quarterly newsletter, please complete the  form below and mail it to: Michigan Polio Network, Inc.
     c/o Don G. Pixley

  517 Oak Street

                    Rochester Hills, MI 48307
Include the mailing label from your newsletter with your old address along with this form.
Thank You.
Name________________________________________________________________

New Address_________________________________________________________

City, State, Zip Code ___________________________________________________

Date new address is effective_____________________________________________