ABG Business Associates, LTD.
"Dedicated to the health care needs of small business"
APPLICATION FOR MEMBERSHIP

Yes. I would like my business to become a member of the MHL Business Group Ltd. Upon acceptance, I will have the opportunity to take advantage of the dozen of the benefits and services that the Business Group offers.     

Please find enclosed my annual membership fee of $40 which covers me and all my employees.

My annual membership fee will be waived as I am a member of   _________________  Association and the annual dues I pay this Association covers my membership with MHL Group.

               ** Number of persons employed by my business: _______

Incompleted applications will result in a delay of processing for benefits

Agent's Name: ___________________________________________
Agency Name: ___________________________________________
Phone: ___________________________________________
Fax: ___________________________________________
Company Contact: ___________________________________________
Company Name:  ___________________________________________
Company Address: ___________________________________________
Print Name: ___________________________________________
Signature: ___________________________________________
Phone: ___________________________________________
Fax: ___________________________________________
Date: ___________________________________________

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