IMACC INDIVIDUAL MEMBERSHIP FORM
| Name College |
| Home Address College Address |
| City, State, Zip City, State, Zip |
| Phone ( ) Phone ( ) |
| 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 distributed with the IMACC data base? |
| Mail to: IMACC | (Circle one) Yes No |
| c/o Dave Clydesdale | |
| Sauk Valley Community College | |
| 173 IL Route # 2 | |
| Dixon, IL 61201 |