Irish American Cultural Institute Chapter Membership Form

Name:

Address:

City/State/Zip:                                                                              
Phone:

E-mail:

Local Chapter:

Payment Info:

Membership Level:
Chapter/National
Member - $25 (one price
for Local/Nat.)
 
Member - $50, Friend - $75,
Sponsor - $100, Patron - $200,
Partner - $500 (These are
Donations above and
beyond Chapter/Nat.
Dues.)

Total Cost submitted for Membership:

Tax free Donation:

Total of both:

Check - to IACI:

Visa or Mastercard:

Card Number/Expiration:

CSC Code (on back of
Credit Card):

Signature:

 
I AM INTERESTED IN PROMOTING MY IRISH HERITAGE IN THE FOLLOWING WAY(S):

Hosting an Event:
Representing IACI at an Event:
Promoting Irish way in my Area:
 
 
Other:

 
 
 
(If you need more room to explain,
you may use the back of this form.)

PLEASE, return to - IACI, POB
# 1716, Morristown, NJ 07962
Ph: 1-(973)-605-1991
E-mail: info@iaci-usa.org


IF YOU NEED A COPY OF THE
APPLICATION, + CANNOT PRINT
E-Mail -- thetrumps1000@gmail.com
AND ONE WILL BE S-MAILED TO YOU!

For inquiries on LOCAL CNY membership
contact - cnychapteriaci@gmail.com