South Dakota

RehabACTion, Inc.

 

___ $35 1 year membership in SD and American RehabACTion

 

___ $68 2 year membership in SD and American RehabACTion

 

 

Please send to Bernie Grimme,  122 North Monroe, Pierre SD 57501 or E-mail to berniegrimme@pie.midco.net  Phone 605-280-6284

 

Name:  ___________________________________

 

Position:  _________________________________

 

Employed by:  _____________________________

 

Mailing Address:  __________________________

 

City,  State, Zip Code:  ______________________

 

E-mail Address:  ___________________________

 

Day Time Phone:  (___)______________________

 

Home Phone:  (___)_________________________

 

Fax Number:  (___)_________________________

 

Referred By:  ___________________________