MIT Enterprise Forum of the Great Lakes -- Membership Application

Name

Title

Company

Address

Mail Address

Telephone		Fax

E-Mail		Website

Products/Services

Please check to indicate your interest in the forum
	Entrepreneur		Investor
	Service Provider		Member-At-Large

Individual Membership
	Regular One-Year $100
	Regular Two-Year $180

You may submit your membership application in one of two ways:
1. Call Barbara Sakis Mon / Tues / Fri a.m. at 248.583.4110 x123 or Wed / Thurs / Fri p.m. at 248.887.6136
2. Press the button below to submit your completed form electronically to MIT Great Lakes



Send check and copy of registration to: Grace Lee Treasurer MITEF Great Lakes 2929 Plymouth Rd. Suite 207 Ann Arbor, MI 48105