MEMBERSHIP APPLICATION

THE 100 CLUB OF GRUNDY COUNTY

PO Box 109

Morris, IL 60450

I hereby make application for membership in the 100 Club of Grundy County.

Name: ______________________________________ Date: ____________________, 20_____

(Please print)

Home Address: _______________________________________________

City/State: ___________________________________ Zip: ____________

Phone: ________________________

Company Name: ______________________________________________

Company Address: ____________________________________________

City/State: ___________________________________ Zip: ____________

Type of Business: ______________________________________________

Email Address: ________________________________________________

PLEASE MAIL ALL CORRESPONDENCE TO ME AT: Home Address ( ) Business Address ( )

Membership Classification:

(All memberships tax deductible in the manner and to the extent provided by law)

_____ Founding Member - $5000.00 one time contribution

_____ Charter Member - $2500.00 one time contribution

_____ Corporate Member - $1500.00 contribution (payable $500.00 annually for 3 years)

_____ Individual Member - $300.00 contribution (payable $100.00 annually for 3 years)

Signature: ___________________________________________________