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DMU- Health Leaders Application

 

Contact Information

Name

 

Mailing Address

 

City, State, Zip Code

 

Home Phone

 

Birth Date

 

E-Mail Address

 
 

Membership Dues

Purchase Membership

Membership to just the DMU Health Leaders student club.  Annual student dues for this level of membership are $25 (US dollars).  The prorated dues payment schedule is as follows: 

Month Applied   Amount Due

January-June    $25.00

July-August      $12.50

September-December $25.00 (Payment will cover next year’s dues in full.)

Please note: Dues are billed in October for subsequent years
 

Payment
Name as it appears on credit card:  
Type of credit card:   
Credit card number (no spaces please): 
Your 3 or 4 digit security code number from your card:
  How to find your security code number:
On a Visa, Discover or MasterCard, please turn your card over and look in the signature strip. You will find (either the entire 16-digit string of your card number, OR just the last 4 digits), followed by a space, followed by a 3-digit number. That 3-digit number is your security code number. On American Express Cards, the security code number is a 4-digit number that appears above the end of your card numbers.
Expiration date: