IVCC BASKETBALL  6TH MAN CLUB

                     APPLICATION

MEMBERSHIP APPLICATION

LEVEL 1 - STARTER - $50.00.........................................$_________

LEVEL 2 - ALL-CONFERENCE - $100.00...................... $_________

LEVEL 3 - ALL-AMERICAN - $200.00.......................... $_________

LEVEL 4 - COACHES CLUB - $500.00...........................$_________

STUDENT MEMBERSHIP - $15.00.................................$_________

SENIOR CITIZEN - $45.00..............................................$_________

TOTAL PACKAGE.........................................................$_________

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(Please Print)

Name_____________________________________________________________

Home Address______________________________________________________

City__________________________________ State__________ Zip___________

Business Address____________________________________________________

City_________________________________ State___________Zip___________

Home Telephone ( ) ________________Business Phone ( )______________

Email Address______________________________________________________

Make Check Payable to : IVCC Basketball 

Mail to :        IVCC  Men's Basketball

                    815 N. Orlando Smith Ave.

                    Oglesby, IL 61348.

For additional applications or questions call (815)224 - 0472.