New or Renewal:
Contact Person:
Title:
Restaurant Name (DBA):
Corporate Name:
Street Address:
Mailing Address:
City:
Zip:
County:
Phone:
Best Time to Call:
Email:
Primary Business:
Comments:
Card Type:
Name on Card:
Card Number:
Expiration Date:
Amount Charged:
If paying by check, make check payable to Michigan Restaurant Association, and mail to: Michigan Restaurant Association; 225 West Washtenaw, Lansing, MI 48933; Phone: 800-968-9668 or 517-482-5244; Fax: 517-482-7663
