The Illinois Classical Conference, Inc.

Application for Membership

School Year:  2006 to 2007 

Please Print Legibly

Please check one option in EACH column:

 

 

_____ NEW (if not a registered member last year)                      _____ FIRST-TIME NEW REGULAR:  $10.00

                                                                                                                                FOR THE FIRST YEAR ONLY

                                                                                                              _____ REGULAR:  $20.00 per annum

($30.00 after Nov. 1^st)

                                                                                                              _____ JOINT:  $30.00 per annum

(husband/wife, $40.00 after

Nov. 1^st)

_____ RENEWAL (please fill in all                                                _____ STUDENT:  $5.00 per annum

            the information below to

            insure our information is accurate.)                                    _____ RETIRED:  $5.00 per annum

                                                                                                              _____ CURRENT LIFE MEMBER

                                                                                                             _____ LIFE MEMBERSHIP:

                                                                                                                                 $300  one time charge

                                                                                                             _____ LIFE JOINT MEMBERSHIP:

                 $450  one time charge

                                                                                                             _______SUSTAINING MEMBER:

                $30.00 before Nov. 1^st

 

Dr.  _____     Prof.  ______     Mr.  ______     Mrs.  ______      Ms.  ______

 

NAME:  LAST:  ___________________________                FIRST:  _______________________

 

HOME ADDRESS:  ______________________________________________________

 

CITY:  ________________________                STATE:  _______ ZIP CODE:  _______________

 

PHONE:  ____________________                    E-MAIL:  __________________________________

 

SCHOOL AFFILIATION:  _________________________________________________

 

ADDRESS:  _____________________________________________________________

 

CITY:  ________________________                STATE:  _______ ZIP CODE:  _______________

 

PHONE:  _____________________                  FAX:  ___________________________

 

 

Please complete all parts of this form

Please make checks payable to

 ILLINOIS CLASSICAL CONFERENCE

 

                                                Return to:             Elizabeth Skoryi

                                                            303 Cedar Lane

                                                                                Shorewood, IL  60404-9721

                                                                                lskoryi@comcast.net