NEMC Application

New England Moxie Congress Membership Form
Please choose one of the following:

New Membership ApplicationChange in Contact DataAnnual Dues PaymentUpgrade to Life Membership
Instructions:
All users must enter today’s date and the name and email address of the Primary Contact.*

For New Member application, fill in the form and select membership category in the Payment section below.

For Family memberships, one additional name and email address may be entered where indicated. “ Family” is defined as two or more related
individuals residing at the same address.

For Business memberships, enter the primary contact’s name and email address, and the name of the business where indicated.

For Annual Dues payment or upgrade to Life membership, primary contact name only is required. Note that yearly memberships are good until the end of the following calendar year and must be renewed or upgraded before that time in
order to insure membership continuity.

For Data Change only, enter all the contact information which has changed (address, email, phone number, etc), then hit "Submit". Do not enter any
payment information.
Today's date*

MonthDayYear
Date
Primary Contact Name *
Primary contact email*
example@example.com
Mailing Address
City
State
Zip
Phone
Moxie related interests and/or any other information you care to share
Enter Business name or Additional Names and Email addresses (only for Business or Family Membership please)

0/20
If this is a Data Change only (no dues payment), after completing the above form as applicable, go directly to “submit’ on the bottom of the page. Do not fill in the remainder of this form.

If you prefer payment by check, fill in the form above only and do not select any payment options below, hit Submit and send a check for the appropriate amount* to:

NEMC Membership

attn: Judy Gross

17 Goodhue Lane

Barre VT 05641
*Membership categories and dues rates (choose one if paying by check):
If paying by credit card via PayPal, select either annual of lifetime membership options below. Note that $1.00 has been added to each fee for CC processing.
prevnext( X )
Membership (Individual) <$1.00 surcharge for CC Payments>One year membership $10, Lifetime membership $100
$11.00 Please select your membership option.



Membership (Family) <$1.00 surcharge for CC Payments>
$16.00 Please select your membership option.



Membership (Business) <$1.00 surcharge for CC Payments>
$26.00 Please select your membership option.



Total

$0.00
Should be Empty:

New England Moxie Congress Membership Form