To join the IMDA Priority Club, complete this form and mail or fax it to the IMDA Office or call us at 217-753-8866.

Annual Membership (1/1/04 - 12/31/04)                $50

Name

_______________________________________________

Address

________________________________________________

City            State                Zip

________________________________________________

Phone                                E-mail Address

________________________________________________

[ ] Check    [ ] MasterCard        [ ] Visa

Account Number                    Expiration Date

________________________________________________

Signature

________________________________________________

Illinois Motorcycle Dealers Association

2000 East Cornell

Springfield, Illinois 62703

217-753-8866    fax 217-753-8897