THE Louis Sullivan Society 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
Donation Amount:
Donation of $1000.00 or more
Amount
Gift Membership Premiums
Add a Print as my premium.
Add a Pin as my premium.
Please do not send me any premium(s).
Payment Information
I will pay by check made payable to Landmarks Preservation Council of Illinois and mail
I will pay by Visa, Master Card or American Express and mail or fax in this form
Date
Credit Card Information
Select Card
Select Credit Card Payment Type Visa Master Card American Express
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