MC 2000 Membership Application

To support MC - 2000 please return this form to:

Mifflin County 2000
6395 SR 103 North, Bldg. 50
Lewistown, PA 17044

Individual Memberships Enclosed is my contribution of: ( ) $10 per each family member ( ) Other amount __________	Corporate Membership Enclosed is my contribution of: ( ) $100 corporate membership ( ) Other amount _________
Please print or type : Name ______________________________ Address ____________________________ ___________________________________ Home Phone ________________________	*Please print or type :* Business Name ______________________ Address ____________________________ Contact Person ______________________ Phone ______________Fax ____________

Make Checks Payable to MC - 2000, Inc. Your donation is tax deductible. Thanks.

Print source: http://www.mifflincounty2000.com