MCHC Membership Enrollment Form

If you would like to become a member of the Maine Cardiovascular Health Council, you can do this online by filling out the information below.  Annual membership rates are listed under "Choose an annual membership category."  

Please note:  An organizational membership ($100) entitles you to the equivalent benefits of five individual memberships.  Please indicate the names of the members in the space provided and include an email address for each.  For provider practice memberships ($200) - please provide us with a list of your providers to be added to our membership list.  Include mailing address, phone number, and email address for each.  You can enter this information in the space provided or mail the information to us at 11 Parkwood Drive, Augusta, ME  04330.

Please provide the following work contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
FAX
E-mail

Please provide the following home contact information:

Street Address
City
State
Zip/Postal Code
Home Phone
E-mail

Choose an annual membership category:


Please send all mailings to me at:


Enter your 4 additional organizational members here (your entry will be listed as the 1st of the 5 members) -- please include an email address for each:


For Provider Practice memberships -- you can enter the names, addresses, and email for each of those in your practice below, or you can mail the information to us at 11 Parkwood Drive, Augusta, ME  04330.

       

Please indicate services you are interested in receiving:

Web Updates on Cardiovascular Topics
Updates via email
Bulletin Board Updates
MCHC Newsletter
Online Conferencing
Women & Heart Health Information

Billing Options:


Author information goes here.
Copyright © 2003 Maine Cardiovascular Health Council. All rights reserved.
Revised: November 02, 2007