Personal Information:
Name: ____________________________________________________
Address: __________________________________________________
City: ___________________________ State: _______ Zip: _________
Phone(day): _______________ Phone(evening): __________________
Email address:________________________________________
Is it okay to contact you via e-mail regarding current legislation or other matters when necessary? ______
Can we e-mail your newsletter or do you prefer to receive it in the mail (please check one)?
____________ e-mail is fine
____________ please mail my newsletter to the address above
Involvement (circle one):
Prisoner / Friend / Professional / Family / Volunteer
Other:____________________
Type of Membership (Check One):
______Prisoner-No Charge *
______Individual-$10.00
______Family-$20.00
______Other
______Please place me on your mailing list.
Enclosed is a donation for postage.
DUES ARE PAYABLE on a yearly basis for one year from the first of the month that you joined.
*Prisoner members need to include MDOC number on all communications to Mississippi CURE. Please make checks payable to MISSISSIPPI CURE.
