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Individual Membership
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Email
*
Your email
Membership Contribution
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Choose
Student - $20
Regular - $30
Believer - $50
Enthusiast - $100
Great - $250
Lifetime - $360
I am part of a Partner Organization
First Name
*
Your answer
Last Name
*
Your answer
Title
Your answer
Affiliation
Your answer
Mailing Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Phone
Your answer
email
*
Your answer
web address
Copy / paste the address to share from a browser page to grab the entire address.
Your answer
Do you want listed in the Membership Directory?
*
Yes, list me in the membership directory
Do not list me in the membership directory
Required
If you said 'yes, list me in the membership directory' please mark what info we may share with other members!
Street Address
Phone number
Email address
I will complete my transaction via:
*
PayPal - Please use the PayPal link on this ICEC web page, you may need to scroll to see the link!
Check - I need an invoice to request payment - invoice will be emailed to the address you provided in this form.
Check - I do NOT need an invoice.
Send me a copy of my responses.
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