2015 MEMBERSHIP APPLICATION

Name ______Birthdate ______

Company ______Title ______
Address ______

City, State, Zip Code ______
Telephone ______FAX ______

*E-mail ______
Chapter Preference: ______

*required information for website profile
Select Membership Category (please select the appropriate payment by month of joining):

IMC Membership payment is renewed on a calendar year basis, therefore your membership is pro-rated when joining

after the first of the year. You receive the same member benefits, and your membership will be due for renewal on December 31, 2015 at the annual renewal rates listed for each category.

□ Professional Member – for those engaged in the profession of management consulting
($325 annual renewal plus a $50 application fee) I am joining:

□ January- March / □ April - June / □ July- September / □ October - December
$375 / $295 / $215 / $455 (includes 2016)

□ Affiliate Member – for those with an interest in the profession, but not practicing consultants

($495 annual renewal plus a $50 application fee) I am joining:

□ January- March / □ April - June / □ July- September / □ October - December
$545 / $425 / $300 / $455 (includes 2016)

□ Student Member – for full time students* with an interest in the profession, who are not yet practicing consultants. *Student members must submit a copy of a valid student ID from an accredited university or college.

($95 annual renewal, no application fee) I am joining:

□ January- March / □ April - June / □ July- September / □ October - December
$95 / $95 / $95 / $95

Preferred Method of Payment:

□ My check for $______payable to “IMC USA” is enclosed.

□ Credit Card: MasterCard VISA American Express

Card Number: ______Exp. Date: ______

Signature: ______

Payments to the IMC USA are not deductible as charitable contributions for federal tax purposes. However, dues payments and application fees may be deductible as ordinary and necessary business expenses.

Mail to: IMC USA, 4440 PGA Boulevard, Suite 600, Palm Beach Gardens, FL 33410 OR
Fax to: 800-837-7321 Office: 561-472-0833

Once your membership application is received by the IMC USA office, please allow 10 to15 days for acknowledgement of membership.

Pledge & Attestation: I have reviewed and agree to comply with all provisions of the IMC USA Code of Ethics (see http://www.imcusa.org/?page=ETHICSCODE for a copy of the IMC USA Code of Ethics) and the Rules of Procedure for Enforcement:

Signature: ______

Date: ______