Name _________________________________

Title   _________________________________

E-Mail Address _________________________

Phone _________________________________

Company/Organization/Community

_______________________________________

Website Address ________________________

Address _______________________________

City, State, Zip _________________________

Membership Category ____________________

Grantor:           $1,000          

Benefactor       $   500          

Partner             $   250          

Contributor      $   100          

Fee ____________     Check Enclosed _______

                                   Please Bill          _______

Send to: Dick West, Treasurer

             West & Co.

             613 Broadway

             Mattoon, IL  61938

Note:    The ECIDC is a not-for-profit. Corporation under I.R.C. Section 501(c) (6), and all membership fees are tax deductible for business purposes.