Hibbing Public Access Television

211 E. Howard Street P.O. Box 712 Hibbing, MN 55746 (218) 263-7557

Hibbing Public Access Television Membership Renewal Date:__________

       Hibbing Public Access Billing Statement - One Year Membership

Name:____________________________________________________

Organization:_______________________________________________

Address:__________________________________________________

Phone:_______________________ Fax:_________________________

E-mail Address:______________________ Web Page:______________

Comments:________________________________________________

                Business / Service Org. Membership        $50.00        _______

                Family Membership                                 $25.00        _______

                Individual Membership                            $15.00        _______

                Senior / Disabled Persons Membership    $10.00        _______

                Benefactor                                              $200.00      _______

                Corporate Sponsor                                 $500.00      _______

                Other Donations                                      $ _______________

                                                    *** This is a tax deductible contribution

                Please send this invoice along with your check or money order to:

                Hibbing Public Access Television

                P.O. Box 712 - Hibbing, MN 55746

                            We are going places .... Come along!!!