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Membership
Application for Membership
         
First Name:   Last name:
         
Address:   City:
         
State:   Zip Code:
         
Country:
   Area Code:
         
HomePhoneNumber:   Email:
         
Fax:   Cell:
         
Name of the company that you work for :    
         
Skills:   Work Number:
         
MembershipChoice:
I would like to be a MIC member
I would like to be a Supportive Member
I would like to be included on the MIC mailing list
         
Select which of the below committees you would like to join:
         
Faith Based Membership   Grief Support Violence Prevention
MIC Office Public Policy Law   Public Relations Parent/FamilySupport
         
Days Available:   Time of day available:
         
If you have lost a loved one to violence, please provide the infomation below:
         
Lost Loved One's FirstName:
         
Lost Loved One's LastName:
         
Birthdate:      
         
Date Murdered:      
         
School that your love one attended (if applicable)
         
Additional information that you would like to share:
         
 
 
   
 
 
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