ACH - Support Main Street Illinois

SELECT MEMBERSHIP TYPE

$50 - Annual Fee if Already a Member of ILBA
$250 - Annual Fee for Coalition and ILBA
$200 - Annual Fee for Coalition Only

I wish for the annual membership fee to be deducted from my share of Net Terminal Income in: *

one annual installment per year
four quarterly installments per year

I acknowledge I am an authorized representative of the Location identified above. Further, I authorize the IGMOA Operator Sponsor to withhold the specified amount from my share of Net Terminal Income either annually or quarterly, as I have indicated above, on a continuing basis. Neither the IGMOA nor the IGMOA Operator Sponsor will make any additional charges other than what is expressly authorized herein. Payment can be discontinued at any time by contacting the IGMOA in writing at IGMOA P.O. Box 167 Morris, IL 60450.

Name *

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Last

Company

Address *

Email *

Phone *

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