MEMBERSHIP
(Please print this out and sent to the SCII. DO NOT give your credit card
number on-line!)
New Member _________________ Renew Membership _________________
| Name |
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| No Changes |
Change of Address or Telephone |
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| Address |
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| City |
State |
Zip |
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| Home Phone |
SCI |
Date of Injury |
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| Work Phone |
Level |
Age when Injured |
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Cause |
Medical Condition |
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Please make check payable to Spinal Cord Injury Association of Illinois and mail to LaGrange Road address or pay by Visa or Mastercard.
Individual/Family - $15/25 - $_______________
Professional - $25/50 - $_______________
Business - $50/100 - $_______________
I am enclosing an additional tax-deductible contribution in the amount of $_______________.
Visa or Mastercard number:____________________________________ Exp. Date:_______________
Signature: ___________________________________________________________
For Office Use:
Date Received:_____________ Acknowledged:_____________ Completed Update:_____________
Sent Form to National Office:_________________ Renewal Date:_________________