
Former Emerald Society of Illinois Member ID # _____________________
Name: Last _____________________________________________________________________________
First ___________________________________ Middle _________________________________________
Home Address ______________________________________________________ Apt # _______________
City, State, Zip __________________________________________________________________________
Home Phone:_________________________________ Work Phone: _______________________________
E-Mail Address _________________________________________________________________________
Department/Unit_________________________________________________________________________
Briefly describe your Irish Heritage: __________________________________________________________
NEW MEMBER SPECIAL for 2008______$15.00(was $30) Recruit/Cadet ____(First year dues waived)
Sponsor __________________________________________________________ Date________________
Renewal____$30.00 Associate ____ $30.00
Retired ____ (Dues are waived, but you must renew membership yearly)
Please remit check payable to:
Emerald Society of Illinois, P.O. Box 557819, Chicago, IL 60655-7819
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Membership Committee Approval______ Denied _______ Date _________________
Emerald Society Member ID Issued__________________ ID Stickers Issued ______________