
Please PRINT all information !
Former Emerald Society of Illinois Member ID# ______________
Name: Last ______________________________________________________________________________
First
___________________________________
Home Address ______________________________________________________ Apt # _______________
City, State, Zip ___________________________________________________________________________
Home Phone:_________________________________ Work Phone: ______________________________
E-Mail Address __________________________________________________________________________
Department/Unit__________________________________________________________________________
Briefly describe your Irish Heritage: __________________________________________________________
_______________________________________________________________________________________
New Member ____ $30.00 Renewal ____ $30.00 Associate ____ $ 30.00
Recruit/Cadet ____ (First year dues waived)
Retired ____ (Dues are waived, but you must renew membership yearly)
Sponsor ________________________________________________________ Date ________________
Please remit check payable to: Emerald Society of Illinois, P.O. Box 557819, Chicago, IL 60655-7819
--------------------------------- Office Use Only ---------------------------------------------------------------------------------
Membership Committee Approval ______ Denied _______ Date _________________
Emerald Society Member ID Issued __________________ ID & Stickers Issued ______________