Mill & Main Dining Membership Registration

Please fill out the form below to sign up for the Mill & Main Membership.

If you prefer to pay for the membership with check or card, please fill out CHECK or CASH in the credit card information section. You may email antonia@millandmainstreet.com for assistance or questions.

Name

First Name

Last Name

Phone

(###)

###

####

Email

Birthday

MM

DD

YYYY

Address

Radio

Weekender | $500 per year

Upstater | $1000 per year

Mill & Main Family | $1500 per year

Payment Method

Credit Card / Debit Card

Check

Cash

Credit Card Number (N/A if paying with CASH or CHECK)

Expiration Date (N/A if paying with CASH or CHECK)

MM

DD

YYYY

Security Code (N/A if paying with CASH or CHECK)

Billing Zip Code (N/A if paying with CASH or CHECK)

Mill & Main Dining Membership Registration

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