Type:	New   Renewal
First Name:
Last Name:
E-mail:
Present Position:
Social Security Number:
Birthdate:
Level:	Elementary Middle School
Sex:	Male Female
Region:
Address:
City:
Zip:
Home Phone:
School District:
County:
School:
School Address:
School City:
School Zip:
School Phone:
School Fax:
School Email:
Method of Payment:	Personal Check	School District Check
	Installment	Payroll Deduction
	Credit Card
	Invoice School using PO#
	Please make checks payable to MEMSPA and send to 1980 N. College Road, Mason, MI  48854
Card Type:	VISAMasterCard
Name on Card:
Card Number:
Security Code:	(3 digit code on back of card near signature)
Expiration Date:	JanFebMarAprMayJunJulAugSepOctNovDec/20082009201020112012201320142015
Amount Charged:	$535.00
Comment/note: