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

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