Application For Membership
Note: Please have ready all the information requested below before filling out the form. Exiting the form before sending it may result in your having to re-enter information when you return.
Organization/
Company Name
Primary Contact
Title
Address
City
State
ZIP
Telephone Number
Fax Number
Nature of Business
SIC Code
Number of Employees
Number of Vehicles
Membership Classification
(see Fee Schedule for details)
Amount of Dues
We will invoice the applying member organization. Membership shall become effective on the date dues are paid and shall continue for a period of one year.s
Your Name
(even if same as above)
Your Title
Your E-Mail address
To submit this form electronically, click the Submit button. Please mail dues separately to address below.
Alternatively, you can print out this form and

1. FAX it to: 312-236-8304
(We will invoice the applying member organization)

OR

2. MAIL it, along with the dues payment, to:
Illinois Safety Council
One North LaSalle Street
Chicago, Illinois 60602

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URL: http://www.ilsafetycouncil.org --- E-mail: isc@ilsafetycouncil.org
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