IMACC Institutional Membership Form (95-96)

Invoice 199596                                                                  
Amount Due $115.00

IMACC Tax ID # 371127733 		Amount of Remittance _________________

Date ____________________________


Signature ___________________________	Title ________________________________

Make Check Payable to: IMACC		Mail to: IMACC
					c/o Dave Clydesdale
Institutional Members receive one	Sauk Valley Community College
complimentary registration at the	173 IL Route # 2
IMACC annual meeting.			Dixon, IL 61201

Institution Name ___________________________________

Address ____________________________________________

President __________________________________________

Vice President (Academics) _________________________

Contact Person _____________________________________

Title ______________________________________________

Phone ______________________________________________