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