Illinois Middle Grades Network - BASIC RENEWAL APPLICATION

Institution Information

School Name: *

Address: *

City:

State: *

Zip Code: *

Phone: *

Fax: *

District Name: *

District City: *

Administrator Information

First Name: *

Last Name: *

Email: *

Complimentary Members

Assign your two Complimentary Individual Memberships.

Member One

First Name:

Last Name:

Email:

Member Two

First Name:

Last Name:

Email:

Billing Information

Payment Options: *

Address if different from above:

Address:

City:

State:

Zip Code:

When you complete the form you will be redirected to an online payment page. If you would rather not pay online, please print this form (by clicking the printer icon below) and mail it to AIMS with your payment.

AIMS
University of Illinois Champaign-Urbana
510 Devonshire Drive
Champaign, IL 61820

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Important Dates