IMACC INSTITUTIONAL MEMBERSHIP FORM (96-97)

Invoice 199697 Amount Due $115.00

IMACC Tax ID # 371127733 Amount of Remittance

Date

Signature Title

Make Check Payable to: IMACC Mail to: IMACC

c/o Dave Clydesdale Institutional Members receive one Sauk Valley Community College complimentary registration at the 173 IL Route # 2

IMACC annual meeting. Dixon, IL 61201

Institution Name Address

President Vice President (Academics)

Contact Person Title Phone