PO Box 301 White Sulphur Springs, MT 59645
406.547.2255 Voice - 406.547.2455 Fax
Membership Form
To become a member of CIIN and receive Our Toxic Times, please print and complete the following
and return it with your tax-deductible donation in any amount to:
CIIN, PO Box 301, White Sulphur Springs, MT 59645 USA.
Name_______________________________________________________________
New Member ______ Renewing Member ______ Past Member ______
Address_____________________________________________________________
City, State, Zip or Postal Code____________________________________________
Country __________________________________________
Phone ___________________________________________
Fax _____________________________________________
Email ____________________________________________
___Send Our Toxic Times via Email (Make sure to provide email address above)
___Enclosed is a check/money order for my donation in the amount of $____________
___Please charge my membership donation of $_________ (not less than $25) to my credit card.
If this is a gift, please include recipient's name: ___________________________________
Name on Credit Card: ___________________________________
___ Mastercard ___ Visa ___ Discover
Credit Card No. _______________________________ (Example: XXXX-XXXX-XXXX-XXXX)
NOTE: Please provide the 3 digit security code located on the back of the card________
Exp. Date _________________________________
Signature _____________________________________
Phone (if not disclosed above) _____________________________
___ Please keep my membership and donation anonymous
___ Please mail me a receipt for my donation. (For donations of $50 and over)