Membership Form

Fill in this form through your web browser
and print, then fax or mail with donation to:

 

Landmarks Illinois
53 W. Jackson Blvd., Suite 1315
Chicago, IL 60604

Tel  (312) 922-1742
Fax (312) 922-8112

 

Contact Information:

 

Name

Title

Organi-
zation

Street
Address

Address
(cont.)

City

State

Zip Code

Home
Phone

Work
Phone

E-mail

 

Membership Level:

 

Select

 

Premiums

 

Add a premium.

Please do not send me any premium(s).

 

Gift Membership Contact Information

 

Please send a gift membership to:

 

Name

Title

Organi-
zation

Street
Address

Address
(cont.)

City

State

Zip Code

Home
Phone

Work
Phone

E-mail

 

Gift Membership Level:

 

Select

 

Gift Membership Premiums

 

Add a premium to my gift membership.

Please do not add any premium(s).

 

Payment Information

 

I will pay by check made payable to
        Landmarks Illinois and mail.

I will pay by Visa, Master Card or American
        Express and mail or fax in this form.

 

Total Amount of Donation

Date

 

Credit Card Information

 

Select

 

After Printing

 

If paying by credit card, please sign and fill in the following credit card  number fields after printing with a pen. Thank you.

 

Signature

Card #

Expiration

Date