Form Center

2. ID#: (Found on Remittance Stub)
4. First Name*
5. Last Name*
7. Job Title*
8. Phone Number*
10. Municipality*
11. State/Province*
12. Country
14. Email Address*
18. Do you need to update any of your membership information?*

    1. No, all of the information on my renewal notice is correct.
    2. Yes, I need to update my information.
20. Which of the following needs updated?

    Check all that apply.

    1. Name
    2. Title
    3. Municipality
    4. Work Address
    5. Work Telephone
    6. Work Fax
    7. Cell Telephone
    8. Home Address
    9. Home Telephone
    10. Email Address
    11. Web Address
    12. Population
22. New Municipality*
24. Municipality You Are Leaving*
26. Did you Replace Someone in your New Municipality?*

    1. Yes
    2. No
28. Please Enter Name of Replaced Employee*
30. Name Change*
32. Title Change*
34. Work Address Change*
36. Work Telephone Change*
37. New Work Fax Number*
39. Web Address Change*
41. Home Address Change*
43. Home Telephone Change*
44. New Cell Number*
46. Which email address will you be updating?*

    1. New Work Email
    2. New Home Email
    3. Both Email Addresses
48. New Work Email *
49. New Home Email*
51. Population Change*
55. Annual Membership Fee*
    -- Select One --Full Member: Population up to 20,000 - $185.00Full Member: 20,001 to 200,000 - $225.00Full Member: Over 200,001 - $285.00Additional Full Member - $125.00Associate Member - $125.00Associate Member-In-Transit - $125.00Retired Member - $35.00Outside of North America - $60.00
57. Membership Renewal
    Membership Renewal
58. Taxable
59. Quantity
60. Shipping Cost
62. Annual Membership Late Fee*
    -- Select One --Yes, I will be submitting a late fee. - 15.00NO, I will not be submitting a late fee. - 0
64. Quantity
65. Shipping Cost
66. Taxable
68. IIMC Foundation Education Contribution*
    -- Select One --Yes, I would like to donate. - $25.00No, thank you. - $0.00
70. Continuing Education
    Continuing Education
71. Quantity
72. Shipping Cost
73. Taxable
Leave This Blank:


74. Calculate Totals Proceed to Checkout

* indicates a required field