Illinois Coin Machine Operators
Association
NAME
_____________________________________________________________
COMPANY
________________________________________________________________________
STREET
ADDRESS __________________________________________________
CITY
__________________________________ COUNTY __________________
STATE
______ ZIP_____________
PHONE
(______)___________________ FAX
(______)__________________
EMAIL _____________________________________
Return
to Members Page
MEMBERSHIP FEES
I
hereby apply for membership in the
ILLINOIS COIN MACHINE OPERATORS ASSOCIATION.
I am an:
_______
OPERATOR - $250 per year
_______
DISTRIBUTOR - $330 per year - Associate Member
_______
MANUFACTURER - $350 per year - Associate Member
_______
SUPPLIER - $150 per year - Associate Member
Sponsored
by _____________________________ _________________________
(Required)
Operator Member
Company
My check is enclosed for membership fees for this fiscal year.
Signed _____________________________________ Date _________________
This
application is subject to the approval of the Board of Directors of the
ILLINOIS
COIN MACHINE OPERATORS ASSOCIATION.
Please Printout and Fax
to Fax: 217-528-6545. Thank you!!!!!