New England Moxie Congress Membership Application
(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 email@example.com and we will email you a receipt!