IMACC INDIVIDUAL MEMBERSHIP FORM
Name	College
Home Address	College Address
City, State Zip	City, State Zip
Phone ( )	Phone ( )
e-mail
To which address should correspondence be sent? (Circle one) Home College
MEMBERSHIP FEES Membership Amount
1 Year $7.00 Scholarship Contribution
3 Years $19.00
5 Years $ 29.00 Total Remittance
Make your check payable to: IMACC Do you wish your name
Mail to: IMACC distributed with the
c/o Dave Clydesdale IMACC data base?
Sauk Valley Community College (Circle one) Yes No
173 IL Route # 2
Dixon, IL 61201