UniForum Chicago Corporate Membership Application Form

Print this page and fill out the information below to apply for Corporate membership in UniForum Chicago for $350 per year. Make checks payable to "UniForum Chicago" and mail to:
UniForum Chicago, User Group Office, P.O. Box 343, Lisle, IL 60532.

Place a check mark in the "do not disclose" column for each item you do not wish disclosed except for purposes of receiving official UniForum Chicago communications. All items except name and address are optional.

 do not
disclose
 _____    Company Name ________________________________________________
 _____    Company Web Address _________________________________________
 _____    Billing Address _____________________________________________
               ________________________________________________________
               ________________________________________________________
 _____    Billing Phone _______________________________________________
 _____    Billing E-Mail Address ______________________________________

          Complementary Individual Membership
 _____    Name ________________________________________________________
 _____    Title _______________________________________________________
 _____    Business Address ____________________________________________
               ________________________________________________________
               ________________________________________________________
 _____    Business Phone ______________________________________________
 _____    E-Mail Address ______________________________________________
 _____    Home Address ________________________________________________
               ________________________________________________________
               ________________________________________________________
               ________________________________________________________
 _____    Home Phone __________________________________________________
 _____    Other Group Affiliations:
	       National UniForum _____  IEEE _____  ACM _____
	       Other __________________________________________________
 _____    Preferred Address to Receive Announcements for Newsletter:
	      Business _____  Home _____     
	  Principal Areas of Interest:
               ________________________________________________________
               ________________________________________________________

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   dues paid date ________  received by ________  office copy ________