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Name:______________________________

Address:_____________________________

Phone:______________________________

Facility:______________________________

Facility Address:_______________________

Facility Phone:________________________

Email:_______________________________

Position/Occupation:____________________

Date:________________________________

Individual Membership Dues:

$24.00 annually

Make check payable to: ANMAP

Send your information and check/money order to:

Dee Collins

ANMAP Treasurer '07-'09

905 N. Jefferson St.

Hobbs, NM 88240