Join MITA Today

MITA International
c/o Fran Hellman, Treasurer
376 Old Woodbury Rd.
Southbury, CT 05488

To pay by credit card download the Charge
Card Payment Form and return it by mail or fax it to the number on the form.

Member Name: *

Name of individual applying for membership

Street Address: *

Street Address of individual applying for membership

Additional Address :

Additional Mailing address information ie. suite, apt., district

City: *

City of residence

State/Province:

State or Province of residence

Zip/Postal Code:

Country: *

Country of residence

Shipping Address:

Shipping Address if different from residence.

Business Name:

Name of the Service Center or Business where applicant works

Business Address:

Address of the Service Center or Business where applicant works

Business Phone: *

A phone number where applicant can be reach by MITA staff.

Fax Number:

Fax number for business purposes

Toll Free Number:

Toll free number used for business purposes

Cell/Mobile number:

Cell or Mobile number used for business

Email Address: *

Email address to be used for MITA business

Web site URL:

URL of Web Site used for business

Products and Services Offered:

Brief description of the products and services offered by your business including service area.