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
 
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!