BINNM Membership Form

To be a member please fill out the Membership form. Memberships is Due in July. All Members must have a mailing address North of US 10. We have PayPal now so you can pay after you fill out the form. You don't have to belong to PayPal to purchase your membership. Just pay by credit card and at the end of the purchase you will be asked to join PayPal or not join. We also have the ability to pay at the meetings as well. If you dont want to pay online you can scroll to the bottom of this page and print the form and mail or bring to a meeting.

Brain Injury Network of Northern Michigan Membership Application
Applicant Information New Renewal
Name:							Date
Credentials:
Organization:
Address:
City:				State:		ZIP Code:
Email address:
Website:
Work:		Home:	Cell:				Fax:
Do you want to be listed on the website				Yes	No
What heading do you want to be listed:
	Membership Options - renewable in July
	Individual ($25.00)
	Corporate ($100.0 – up to 5 Members)
	Additional Corporate Member ($20.00/member)
Total Members
Grand Total

You can also print the form and mail or bring to a meeting.

Membership Form
Mail to
BINNM
2175 Cove Dr
Traverse City, MI 49685

Our mission is to educate and empower our members, providers and the community in the treatment and recovery from brain injuries.

Quarterly Meeting
Thursday October 17
Dr. Porter will be presenting at Foster Family Community Health Center (Meeting Rooms A & B) from 6 - 8 PM

Brain Injury Network of Northern Michigan
Membership Application

Applicant Information
New Renewal

Membership Options - renewable in July

If your not on the mailing list click mailchimp and fill it out

Brain Injury Network of Northern Michigan

About this site

Information on the Brain Injury Network
of Northern Michigan website is
presented as public service Information
It is not intended to be nor is a
substitute for professional medical and
rehabilitation advice

Site maintained by Steve Purkiss CRC webmaster@braininjurynorth.com