Association Membership Application Form

2022 Illinois Professional Emergency Management Association Membership Application
Type of Membership

Individual No Sponsor (No Voting Rights)County/Agency/Corporation 1-5 Members = one association voteCounty/Agency/Corporation 1-10 Members = one association voteCounty/Agency/Corporation 1-20 Members = one association voteCounty/Agency/Corporation 1-30 Members = one association voteCounty/Agency/Corporation 1-40 Members = one association voteStudent (No Voting Rights)
County/Agency/ Corporation*
Number of Individuals
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Point of Contact Name

First NameLast Name
Email*
Office Phone*

Area CodePhone Number
Cell

Area CodePhone Number
Personal Contact Information
Please include names and emails of all individuals that would like to be members of the Association
The following is only for Individuals that want to be members of the Association
Individual or Student Name

First NameLast Name
Applicant Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Number

Area CodePhone Number
Personal Email
example@example.com
E-Signature Name*
Date*

MonthDayYear
Date
Should be Empty:

2022 Illinois Professional Emergency Management Association Membership Application