ICON MEMBERSHIP APPLICATION

NAME_____________________________ E-MAIL ADDRESS_______________________

HOME ADDRESS___________________________ HOME PHONE __________________

CITY_____________________________  STATE_____ ZIP__________  DATE_________

 YEARLY DUES $20.00 + $5.00 APPLICATION FEE = $25.00

CIRCLE WORD THAT DESCRIBES YOUR EXPERTISE IN COMPUTING

     BEGINNER           INTERMEDIATE               ADVANCED          POWER USER

How long have you had a computer?____________ 

Were you referred by someone?    If so, who?________________________________

Mail completed form and $25 to:
ICON
1325 W. Sunshine, #169
Springfield, MO 65807