Minnesota Citizens Federation -Northeast Application
2110 W. First St. Suite 102
Duluth Minnesota 55806 		Return to MCF-NE
Date: ______/______/_______
Full Name: ________________________________________
Street Address: ________________________________________
________________________________________
City: ________________________________________
State: ________________________________________
Zip: ________________________________________
Phone: (____) ____ - ______
Year of Birth:
(optional) 		_____________
Payment Method:

Program fees for:
Renewal/ New Member
(check programs to enroll)
Annual Dues: $15 per person
Drug Imports: $5 per year
Senior Partners Care: $25 per year

Check / Money Order / Credit Card
Make Checks payable to Minnesota Citizens Federation
Card Type:
Visa / MasterCard
Card Number: _______________________

Tax deductible donation: $__________

Expiration Date (month/year): _____/20___ Total Payment: $___________

Signature: ________________________________________________ Date: ____/____/______