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

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