MAHOMET AQUIFER CONSORTIUM

MEMBERSHIP APPLICATION

 

PLEASE PRINT

NAME: (Organization, Company, or Individual

 

 

ADDRESS:  (Street and/or P.O. Box)

 

 

CITY:

 

STATE:

ZIP:

PHONE: (Include area code and extension if applicable)

 

FAX:  (Include area code)

 

 

e-mail:

I, the undersigned, am authorized to request membership in the Mahomet Aquifer Consortium for the above listed organization, company, or individual.

 

Signed:

 

Date:

 

PRINTED NAME:

 

MAC: MEMBERSHIP CARD

 

Please mail this completed form to MAC, 201 Devonshire Drive, Champaign, IL  61820