Membership Form

2012 BIMC Membership Form (printable form)

Membership Dues - $10 (Jan-Dec 2012)

Please make checks payable to: BIMC

PLEASE PRINT CLEARLY - THANK YOU!

First Name:________________________________________________________________

Last Name_________________________________________________________________

Address___________________________________________________________________

PO Box (if applicable) _______________________________________________________

City______________________________________________________________________

State________________________________Zip__________________________________

CellPhone #______________________________________________________________

please include area code

Home Phone#____________________________________________________________

please include area code

E-Mail___________________________________________________________________

________________________________________________________________________

Member Signature Date

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Authorized use only

Date Payment Received________________ Check/MO #___________

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PLEASE PRINT FORM, MAKE CHECKS PAYABLE TO - BIMC - RETURN TO:

Steve Love, CPA/BIMC Treasurer

c/o Love, Cody and Company, CPAs, PC

PO Box 319

Bennington, VT 05201

updated: 01/30/2012

BIMC