Membership Dues

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Membership Dues Amount

One-Time Monthly Yearly

$100 $250 $500 $1,000 Other $

I'd like to help cover the transaction fees for my donation

Contact Information

Congregation Name

Street Address

Postal Code City State

Congregation Email (Optional) Congregation Phone (Optional)

First Name Last Name

Email Mobile Phone

(Optional)

Payment Information

Card Number

Expiration Date

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Eligibility

I confirm that the following statements are true and accurate

I am authorized to sign up for Live Free Illinois membership on behalf of my congregation.

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