(Note: can be used also for membership renewals)

Primary Name  _____________________________________________________________ 

Secondary name (for Family membership) _________________________________________

Phone ___________________ E-mail ___________________________________________

Street address ______________________________________________________________

City _________________________________________ State _______ Zip ______________

Moxie-related interests/other info to share __________________________________________

__________________________________________________________________________

Yearly memberships: Individual ($10) ______ Family ($15) _____ Business ($25)______

Lifetime Memberships: Individual ($100) _____ Family ($150)_____Business ($250)_____

Upgrade: Individual Life to Business Life ($150) _____

Option 1: Copy and print this form and mail with check or MO made out to NEMC to:

NEMC Membership, attn: Kurt Kabelac, 2783 N. Triphammer Road, Ithaca NY 14850.

Option 2: If you have a PayPal account, email a summary of the above info and send your PayPal

payment (dues at rate shown above plus $1.00 for handling fee) to moxiemadcab@comcast.net and we will email you a receipt!