NAME: ______________________MxCC ID#:_____________
See Name Tag - members only
Name tag to read:___________________________________
Address:__________________________________________
City:____________________________ ZIP:
_____________
Phone: __________________E-Mail: ____________________
|
Birth Date____________
New Member Only |
Required of New Members
Soc.Sec.# _______________ |
|
Mail to: MILE
Middlesex
Community College
100 Training Hill Road
Middletown CT 06457
|
Method of Payment (Circle One)
Check ($ .00)
payable to MxCC
Charge to: Visa / Master
Charge
Account #____________________
Expiration Date _______________ |
