IMACC INDIVIDUAL MEMBERSHIP FORM
Name____________________________ College _____________________________
Home Address_______________________ College Address___________________________
_______________________________ _________________________________
City_____________State___ Zip _______ City______________State____ Zip ______
Phone: H- (___ ) ____________________ Phone: W- (___ ) ________________________
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
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