| 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? (Circle one) Yes No | ||||
| Mail to: IMACC
c/o Dave Clydesdale Sauk Valley Community College 173 IL Route # 2 Dixon, IL 61201 |
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