IMACC Individual Membership Form

Name _________________________________  College _______________________________

Home Address _________________________  College Address _______________________

City/ST/Zip __________________________  City/ST/Zip ___________________________

Phone ( ___ ) ________________________  Phone ( ___ ) ________________________

e-mail _______________________________

To which address should correspondence be sent? (Circle one)  Home  College 

MEMBERSHIP FEES			Membership Amount ___________________________
1 Year      $7.00
2 Years    $19.00		Scholarship Contribution ______________________
3 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