TEST membership form, including processing fees

This is a DRAFT FORM for testing addition of $0.30 per transaction + 2.9% of subtotal for Square processing fees.

SUBMITTING THIS FORM WILL ACTUALLY MAKE A PAYMENT.

Comments

This field is for validation purposes and should be left unchanged.

Contact Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Email(Required)

Enter Email Confirm Email

Springfield Ward Number(Required)

Name of Alderperson

Issues of Interest

What ICON issues are of interest to you?

Neighborhood Association or Organization (if applicable)

Name of Association

Association Contact

Association Phone

Association Email

Association Website

Membership Type

Membership renewals are due in January of each year.

Please register me for(Required)

$25 Annual Individual Member (1 vote)

$25 Annual Organization Member (non-voting)

Payment Type(Required)

Please note: Our credit card payment processor charges us a fee of about 3% per transaction, and we pass that on to you for credit card payments. If you wish to avoid paying the fee, please send a check instead.

Credit Card

Check

Make an additional donation to ICON:

(OPTIONAL)

Processing Fee

For credit card payments only.

Price: $0.00

Credit Card payments will be processed via Square.
After clicking “Submit Membership Application”, a popup window from Square will display for you to complete payment.
ICON membership is tax-deductible.

Make checks payable to ICON.
ICON membership is tax-deductible.

Mail to:
Donna Mathis, ICON Treasurer
2119 S Renfro St
Springfield, IL 62703

Total

Membership Agreement

Do you support ICON’s mission to improve the quality of life for Springfield neighborhood residents?(Required)

Yes, as a member, I support ICON’s mission to improve the quality of life for Springfield neighborhood residents.

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Credit Card

Cardholder Name

Card Details