UIC Flames
Official Store

Membership Information

First Name *

Last Name *

Home Address *

City *

State *

Zip *

Home Phone Number

Work Phone Number

Email Address *

Sport(s)

Years (YYYY-YYYY)

Billing Information*
Check box if billing address is the same as membership address

Billing Address for Credit Card

City *

State *

Zip *

Membership dues are $30 for one year. You will be contacted for credit card information after submission of this form.

Notes

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