Detroit Medical Center

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Welcome to the DMC GUILD

DMC GUILD Membership Application

* required fields

Date:

Membership Information:

Dues:

*
$25 Annual $500 Life Membership

Personal Information:

First Name:
*
Last Name:
*

Address:
*

City:
*

State:

*
Zip Code:
*

Residence Phone:
*

Email Address:
*

Payment Information:

Total Amount:
$ *

Method of Payment:
*

Name on Card:
* The same as the above

Credit Card Number:
*

Exp. Month:

*
Exp. Year:
*

CVC:
* (last 3 digits in signature space on back of card)

Other Information:

Spouse's Name:

Business Name & Address:

Type of Business:

Position:

Business Phone:
*

Business Fax:
*

Correspondence Sent:

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I would be willing to serve on a committee:

Walk DMC Membership

Nite on the River Won from the Heart

Auction Golf Outing

I hereby apply for membership and agree to support the goals and objectives of the DMC Guild.
MICS 11200

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