20-30-40 GLASS SOCIETY of ILLINOIS

MEMBERSHIP FORM Please copy and complete this form and mail it along with your check.
NAME(s): ADDRESS: CITY, STATE, ZIP: AREA & TELEPHONE: EMAIL ADDRESS: DATE:
2011   ANNUAL MEMBERSHIP DUES: Individual member - $25.00 Each additional person (same address) - $13.00 Please make your check payable to the: 20-30-40 Glass Society of Illinois. Mail this form and your check to: The 20-30-40 Glass Society of Illinois, P. O. BOX 856, La Grange, Illinois 60525 **Note: Annual Memberships are renewed on December 1st.