Membership Information

First Name *

Last Name *

Home Address *

City *

State *

Zip *

Home Phone Number

Work Phone Number

Email Address

Sport(s)

Years (YYYY-YYYY)

Billing Information*
Check box if billing address is the same as membership address

Billing Address for Credit Card

City *

State *

Zip *

Payment Information

Credit Card *
Visa     Master Card    
Account Number *

Name on Credit Card*

Expiration Date MM/YY *

CVV# (3-digit security number on back of credit card)*

UIC Athletic Alumni Polo Shirt Ordering Information

Number of Shirts

Male/Female
Male     Female
Size
Choose Size Male-Medium Male-Large Male-X-Large Male-XX-Large Female-Small Female-Medium Female-Large Female-X-Large
Notes