___Yes! I would like to join the Northern WI AHEC, Inc.

2-50

51-250

251-500

501-1000+

$150.00

$350.00

$650.00

$1,000.00

Title___________________________________________

Organization_____________________________________

Address________________________________________

City/State______________________________________

Zip___________________________________________

Phone_______________Fax_______________________

E-mail________________________________________

Organization's website address (for inclusion on NAHEC's web page)_________________________________________

Northern WI Area Health Education Center, Inc.
719 N. Third Ave
Wausau, WI
54401