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2. This form is to be used when making a payment using Credit Cards only.
   
   IF YOU ARE EXPERIENCING ANY ISSUES WITH YOUR ONLINE PAYMENT, PLEASE CONTACT JANET PANTALEON by email at janetp@iimc.com or by Phone at (909)944-4162
   
   If submitting payment by check please click here to download the form required for mailing a payment.

   Athenian Leadership Society Enrollment Form

4. Member ID Number*
   If you do not know your member ID number please contact us at (909)944-4162 and a team member can assist you.
6. Last Name*
7. First Name*
8. Current Job Title*
10. Municipality or Government Unit*
12. Mailing Address*
14. City*
15. State/Province*
16. Zip/Postal Code
18. Country
20. Email Address*
21. Phone Number*
23. Athenian Leadership Society Registration Fee
24. Payment
    -- Select One --Yes, I wish to enroll in the Athenian Leadership Society - $15.00No, I do not wish to enroll in the Athenian Society - 0.00
25. Quantity
26. Shipping Cost
28. Taxable
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29. Calculate Totals Proceed to Checkout

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