ICI Membership Enrollment Form

ICI Membership
On-Line Enrollment Form

Name:

First:

M.I.

Last:

Suffix:

Email:	type:
Alt Email: type:
Note: Please notify ICI if you change your email so that we can update our records

Business Address:

Company:

Bus Phone:

Address:

Country:

City:

State:

Zip:

Home Address:

Address:

Home Phone:

City:

State:

Zip:

Send Mail To:

Business
Home

Payment
ICI Membership Fee is $50 USD per year. You may choose to pay online or pay by check. Enrollment application will not be processed until payment is received.

Payment method:

on-line payment*

check being forwarded

invoice

* payment via paypal. You DO NOT need a paypal account to pay online with paypal.

Payment method is required to complete your membership enrollment. If "Invoice" is selected, a P.O. Number is required for the application to be processed. Invoice orders submitted without a P.O. Number will be invoiced ONLY and the application will be processed when the payment is received.

P.O. Number:

Paypal online credit card processing payment is available: You do not need a paypal account to pay online via paypal.

After clicking submit you will be directed to a Thank You page containing the information submitted. A confirmation email that your application and payment are being processed.