Mail Form and Fees To:

Barbara Henley, ICBCHE Treasurer

Vice Chancellor for Student Affairs & Enrollment Management

University of Illinois at Chicago M/C 600

1200 W. Harrison Street, SSB 3010

Chicago, IL 60607-7165

Name_______________________________________

Title______________________________________

College/Department_________________________

Organization_______________________________

Address____________________________________

City/State_________________________________

Zip Code___________________________________

Daytime Phone (     )______________________

Fax (    )_________________________________

E-mail Address_____________________________

Type of Memberships:

(   ) Professional             $ 25

(   ) Student                  $  5

(   ) Institutional            $200

Total Enclosed $_______________________

   (Make check payable to ICBCHE)

NOTE: Individual memberships expire on October 30th of each year.       Institutional memberships expire on June 30th.  

      ICBCHE Federal Employer Identification Number (FEIN): 37-1136208