Membership Form Membership Form Please use this form to apply for membership in Network 49. Membership is $30 per 12 month period per person. Membership is open to any person who is a resident of the 49th Ward of Chicago. Name First Last Email (if you do not have email, enter "N/A" Street Address Untitled First Choice Second Choice Third Choice Unit or Suite #, if applicable City State Zipcode Phone Number Are you interested in becoming a member of Network 49? Yes No Are you a current resident of the 49th Ward Yes No Not Sure Are you a registered voter in the 49th Ward? Yes No Not sure Are you interested in volunteering with one of our committees? Yes, Housing & Community Development Yes, Politics Yes, Safe Communities Task Force Yes, Education Not sure/maybe Not at this time Payment Pay by Credit Card (https://squareup.com/store/network-49) Pay by Check (membership not active till payment recieved) Request hardship waiver Please enter your name as it is signed. Once you have submitted this form, you will need to submit a payment of $30 by check to Network 49, c/o Thom Clark, 1927 W Farwell Ave., Chicago, Il 60626. You may also pay online - click the link at the right side of the page. Upon receipt of payment, your name will be added to the Network 49 Membership list. If you're not a fish leave this field blank: Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window)Click to email this to a friend (Opens in new window)