ILLINOIS CLASSICAL CONFERENCE

Application for Individual Membership

School Year: 2009 to 2010

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. 1st)

_____ JOINT: $30.00 per annum

(husband/wife, $40.00 after Nov. 1st)

_____ 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. 1st

 

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 check payable to

ILLINOIS CLASSICAL CONFERENCE

Return to: Elizabeth Skoryi

303 Cedar Lane

Shorewood, IL 60404-9721

lskoryi@comcast.net

Make additional copies and pass on to a colleague who might be interested in joining! Nil non mortale tenemus

Pectoris exceptis ingeniique bonis.

Ovid. Tristia, III.7.43