Mothers In Charge

Application for Membership
First Name:			Last name:
Address:			City:
State:			Zip Code:
Country:			Area Code:
HomePhoneNumber:			Email:
Fax:			Cell:
Name of the company that you work for :
Skills:			Work Number:
MembershipChoice:	I would like to be a MIC member I would like to be a Supportive Member I would like to be included on the MIC mailing list
Select which of the below committees you would like to join:
Faith Based	Membership		Grief Support	Violence Prevention
MIC Office	Public Policy Law		Public Relations	Parent/FamilySupport
Days Available:			Time of day available:
If you have lost a loved one to violence, please provide the infomation below:
Lost Loved One's FirstName:
Lost Loved One's LastName:
Birthdate:
Date Murdered:
School that your love one attended (if applicable)
Additional information that you would like to share: