Name: E-mail: Business/Organization: Billing Address: Mailing Address (if different from billing): Phone Number: Type of Patron Level Requested: Select patron category: _________________________________________ Individual Patron - $75 Professional Patron - $200 Business Patron - $500 Payment: A bill will be sent to the supplied address, or you may print this form and mail with a check to: Maine Municipal Association 60 Community Drive Augusta, ME 04330
Name:
E-mail:
Business/Organization:
Billing Address:
Mailing Address (if different from billing):
Phone Number:
Type of Patron Level Requested: Select patron category: _________________________________________ Individual Patron - $75 Professional Patron - $200 Business Patron - $500
Payment: A bill will be sent to the supplied address, or you may print this form and mail with a check to:
Maine Municipal Association 60 Community Drive Augusta, ME 04330
