MCHC Membership Enrollment Form

To become a member of the Maine Cardiovascular Health Council, please fill out the form below.
Click here for a printer friendly version.

Please note: An organizational membership ($200) 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.

Annual membership categories:

Please provide the following work contact information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip Code
Work Phone
Fax
Email

Please provide the following home contact information:

Street Address
Address (cont.)
City
State
Zip Code
Home Phone
Email

Please send all mailings to me at:

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

Name
Email

Please indicate services you are interested in receiving:
Web Updates on Cardiovascular Topics
Updates via email
Online Conferencing
Women & Heart Health Information
Legislative Updates

Billing Options:

PROMOTING CARDIOVASCULAR HEALTH THROUGHOUT MAINE'S COMMUNITIES

MCHC Membership Enrollment Form