mhin application by KISUG797

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									                                      ► MHIN ◄
           MID-AMERICA HEALTHCARE INVESTORS NETWORK
                                 Membership Application




Firm Name:________________________________________________________________________

Contact Name: _____________________________________ Title: ___________________________________


        Address:              _________________________________________________________________
        City: ___________________________________ State: _________ Zip: ___________
        Phone:        ________________________________
        Fax:        __________________________________
        Email:       _________________________________




                   Annual Membership — January 1, 2009 to January 1, 2010

    Membership in MHIN is on a per company basis and is not transferable or refundable

   Check payable to MHIN enclosed                                          Amount: $500.0000

   Please enclose the list of all members of the Firm that may attend MHIN functions

  I certify that the above named venture capital firm has over $10M in callable capital under
management




                           Please return this form with your payment

                            Mail to: Amy Gregor
                                     Prolog Ventures
                                     7733 Forsyth Blvd. #1440
                                     St Louis MO. 63105
                                     Phone: 314-743 2400
Members of the firm that may attend MHIN Meetings (return with membership form)


Name: _____________________________________ email: ___________________________________

Name: _____________________________________ email: ___________________________________

Name: _____________________________________ email: ___________________________________

Name: _____________________________________ email: ___________________________________

Name: _____________________________________ email: ___________________________________

								
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