| IMACC INDIVIDUAL MEMBERSHIP FORM | ||
| Name____________________________ | College _____________________________ | |
| Home Address_______________________ | College Address___________________________ | |
| _______________________________ | _________________________________ | |
| City_____________State___ Zip _______ City______________State____ Zip ______ | ||
| Phone: H- (___ ) ____________________ Phone: W- (___ ) ________________________ | ||
| 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 | |
| Make your check payable to: |
IMACC |
Total Remittance = |
| c/o Dave Clydesdale | Do you wish your name distributed with the IMACC data base? | |
| Sauk Valley Community College | ||
| 173 IL Route # 2 | (Circle one) Yes No | |
| Dixon, IL 61201 | ||