Please print this form and mail it with your contribution to:

Mackinac Center for Public Policy
140 W. Main Street
P.O. Box 568
Midland, MI 48640

NAME:

_______________________________

ADDRESS:

_______________________________

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CITY:

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STATE:

_______________________________

ZIP:

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E-MAIL:

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TELEPHONE:

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AMOUNT:

___ $100.00 - $499.00 annual contribution - Mackinac Center Member

___ $500.00 - $999.00 annual contribution - Jefferson Society

___ $1,000.00 - $9,999.00 annual contribution - President's Council

___ $10,000 or higher annual contribution - 1851 Society

___ $10,000 or higher irrevocable pledge through estate planning - Legacy Society

___ Other: $___________

PAY BY:

___ Credit Card ___ Check (enclosed)

Credit Card Type:

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C.C. Number:

_______________________________

Expiration Date:

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Signature:

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Name on Card:

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