New Member Info Form

Please fill out the form below. If you have not already sent payment in, please do so! Membership dues are $25 and should be submitted by April 30. You can pay in one of the following ways:

By check: Make it payable to CLCU and mail it to:
CLCU
PO Box 17493
Urbana, IL 61803

By PayPal: Send your payment to CLCUtreas@gmail.com. Please select "Friends and Family" to avoid additional fees.

Name

First Name

Last Name

Business Name (if applicable)

Medium (if you use more than one, please list top 3)

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What information do you want on the website?

All provided Information

Name and Media Only

Name, Media, and Website/Social Media

Name, Media, and Email

Do Not List Any Information on website

Website

http://

Facebook (please include full web address)

http://

Instagram (please include full web address)

http://

Additional Social Media Sites, please include full web address

Brief Bio (this will be used on website as written)

Let’s work together

Name

First Name

Last Name

Phone

(###)

###

####

What services are you interested in?

Option 1

Option 2

Option 3

Preferred Date

YYYY

What is your budget?

How did you hear about us?

Message