Membership Application

(Please print this page and fill in the following information to become a member.)

Name: ____________________________________

Address: _________________________________

City: _____________________________________

State: __________________ Zip: _____________

Phone: ___________________________________

Email:  ___________________________________

Type of Membership (Please check one)

Annual($25.00)         Lifetime($500.00)

New ________________ Renewal ____________

List Family Members (If Family Membership)

__________________________________________

__________________________________________

__________________________________________

__________________________________________

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Please mail to:

MPHA

 P.O. Box 112

 Mt. Olivet, KY  41064

 606.724.2591