Download Illinois Pioneer Coalition Membership Application

Illinois Pioneer Coalition Membership Application
By becoming a member of the Illinois Pioneer Coalition, you are showing your support for
person centered elder care throughout IL. The funds received for membership go
directly to creating education and training programs for long term care entities throughout
our state.
Select Membership type: Membership is good for one year from the month the payment is received
 Individual - $50 per year
Name:
Address:
Phone:
Email:
 Community - $150 per year (includes ability to link your Facility’s website from the IPC membership page; please
check appropriate box if you are interested in this and our Webpage manger will contact you for further information)
 Interested in connecting facility website from the IPC membership page
Community Name:
Contact Person:
Community Address:
Community Phone:
Community Fax:
Email:
 Trade Association / Vender - $300 per year (includes ability to link your company’s website from the IPC
membership page; please check appropriate box if you are interested in this and our Webpage manger will contact
you for further information)
 Interested in connecting company website from the IPC membership page
Business Name:
Contact Person:
Business Address:
Business Phone:
Business Fax:
Email:
 (coming soon!) Pay by Paypal: (click here to be directed to paypal)
 Pay by check:
 Make check payable to Illinois Pioneer Coalition
 Mail this form and check to: IPC Membership Services
4215 FF Road
Columbia IL 62236