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Estate Planning and Michigan

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					                          Southwestern Michigan




                                           Council

                                  2009-2010
                         MEMBERSHIP INFORMATION FORM
Print out this form (if obtained from the Web site or emailed), fill it in, and mail it along with a
check for your annual dues of $70 to the address listed below. Provide the information just as
you would like it to appear on the Web page for Southwestern Michigan Estate Planning
Council.

   Area of Service: (Check all that apply to you):
        Attorney                                           Insurance/Investment
                                                               Professional
        Certified Financial Planner                          Planned Giving Specialist
        Certified Public Accountant                        Financial Professional

                                           PLEASE PRINT:


   Name: ________________________________________________________________

   Title: _________________________________________________________________

   Company: _____________________________________________________________

   Business Address: _______________________________________________________

   City:_______________________________ State: ____________ Zip:_____________

   Business Phone: (_____)____________________ Fax: (_____)__________________

   E-Mail: _______________________________________________________________

   Your Business Website Address: __________________________________________

   Make Check Payable to: Southwestern Michigan Estate Planning Council


   Mail your check & form to:                                   Office Use Only
   Berrien Community Foundation
   Attn: Nanette Keiser, Ed.D.                       Date Received: _____/_____/_____
   2900 S. State St., Suite 2 East                   Check #: _____________________
   St. Joseph, MI 49085
                                                     Posted/Website:_____/_____/_____

				
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