Affiliate Membership Application

Fill out the fields on this form and submit to the Chapter.  Print the conformation page to send with your check to the following address:

The American Institute of Architects

Eastern Illinois Chapter

P.O. Box 1476

Homewood, Illinois 60430

Affiliate Membership Application

Please provide the following contact information for your business address:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Please provide the following contact information for home address:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone

Mailing Should be sent to:

Business
Residence

Do you hold a certificate of registration as an architect or licensed to practice architecture?

Yes
No

I declare that I will comply with the By-laws, the Rules and Regulations, and the Rules of Conduct of the Eastern Illinois Chapter of the American Institute of Architects.

I Do
I Don't

Enter your check number for the amount of $95.00 (payable to AIA/EIC) being prepayment of the first annual dues. I understand that this amount will be returned to me if I am not admitted to membership in the Chapter.

Date of birth (optional):

-- mm/dd/yy


Copyright © 2004 AIAEIC. All rights reserved.
Revised: 08/29/05