All New Member form

The Academy of Lifelong Learning (A.L.L.) at Lincoln Land Community College NEW MEMBER 2016–2017 If you do not already ...

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The Academy of Lifelong Learning (A.L.L.) at Lincoln Land Community College

NEW MEMBER 2016–2017 If you do not already have a LLCC student account on file, Registration Services will generate a Student ID number through this one-time request of private information. You will only need to provide your Student ID when registering for any Community Learning or ALL class events. PLEASE NOTE: LLCC and ALL recognize and respect the importance of privacy and confidentiality of personal information! We will not publish this in the ALL Membership Directory, nor will we distribute to any third party or outside agencies.

Date of Birth (m/d/yy)

Social Security Number (SSN)

LAST NAME

FIRST NAME [ ] *NAMETAG [ ] *Please select if you prefer to be addressed by a different name.

MAILING ADDRESS

CITY

STATE

ZIP

Please indicate whether any of this information can be published in the ALL Membership Directory only: Home Phone □ Yes □ No Cell Phone □ Yes □ No Email □ Yes □ No

Annual Membership Fee per person for fiscal year July 1, 2016 through June 30, 2017: Please select one

] BASIC ALL MEMBERSHIP FEE ...................................................................................................... $60

[

 OR 

] SPECIAL ALL PLUS MEMBERSHIP FEE .................................................................. $120

[

REFERRED BY ALL MEMBER: PAYMENT METHOD: [

] CHECK Must be made payable to LLCC

[

] CREDIT CARD

[ ] Visa

CHECK #_ ___________

[ ] MasterCard

[ ] Discover

CHECK AMOUNT $ CHARGE AMOUNT $

16-digit card number Expiration Date

SEC

Signature

Please return this form and payment to: Lincoln Land Community College, ATTN: Community Education/ALL PO Box 19256, Springfield, IL 62794-9256 FOR OFFICE USE ONLY

□ DATE RECEIVED

□ PERC