| 2009-2010 Membership Application Employee Benefits Association of Northern Illinois founded 1978 Please print and attach a business card Name:________________________________________________________________ Title:_________________________________________________________________ Employer:_____________________________________________________________ Address:______________________________________________________________ City, State, Zip Code:___________________________________________________ E-Mail Address:________________________________________________________ Phone:___________________________ Fax:________________________________ Type of Business:______________________________________________________ How long have you been an EBANI member? ___New Member ___Member for _____ years Is your membership ___Company paid? ___Individually paid? What topics interest you for upcoming luncheon speakers? ______________________________________________________________________ Are you interested in becoming a future EBANI board member? yes___ no___ Are you interested in volunteering on a committee this year? yes___ no___ If so, which committee: ___Membership ___Administrative ___Newsletter ___Mentoring Other:____________________________________________________ Are you willing to receive further EBANI correspondence by e-mail? yes__no__ Sign _________________________________________ Date ___/___/___ Please print out application and mail along with check made payable to EBANI to: EBANI Attn: Membership Chairperson P.O. Box 4093 Rockford, IL 61110-0593 |
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