INTEGRA ~ Membership Application

Name (first,last)
Address
City
State
Zip
Day Phone	( )
Eve Phone	( )
Cell Phone	( )
E-Mail
(Be sure to include your e-mail address as much of our information will be sent via e-mail and the web.)

My check for $______ is enclosed (make check payable to: INTEGRA)
Add my donation for Integra's work (tax deductible) $__________

		Total: _____________

Fill out this form then click Print Form
Mail form with payment to:
	INTEGRA PO Box 6013 East Lansing, MI 48826