
Name: Last _____________________________________________________________________________
First ___________________________________ Middle _________________________________________
Home Address ______________________________________________________ Apt # _______________
City, State, Zip __________________________________________________________________________
Home Phone:_________________________________ Work Phone: _______________________________
E-Mail Address _________________________________________________________________________
Department/Unit_________________________________________________________________________
Briefly describe your Irish Heritage: __________________________________________________________
Sponsor __________________________________________________________ Date________________
NEW MEMBER SPECIAL for 2010 _______ $15.00 (was $30)
Probationary Police Officer (Less than 18 months on job): _______ Free
_______ I would like to receive my correspondence when possible (including newsletters) by E-Mail.
I understand that it is my responsibility to update my e-mail address by sending the information to:
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Please remit check payable to: Emerald Society of Illinois, P.O. Box 557819, Chicago, IL 60655-7819
Please fill out completely and legibly so you are sure to receive newsletters. Please check the label on newsletters for errors. If you are current and there is a need for change please email to the address above or contact Jim McCarthy at the above P.O. Box, or by telephone at 847-336-6939.
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Membership Committee Approval______ Denied _______ Date _________________
Emerald Society Member ID Issued__________________ ID Stickers Issued ______________