Individual Application

Name:
Address:
City:
County:
State:
Zip:
Home Phone:		Home Fax:
Work Phone:
e-mail:
URL: http://
How many horses do you own?
Where are they kept?	at home	boarding stable
Type of Membership:	Lifetime w/ NO Insurance: $200
	Individual: $39 per year
Amount Enclosed:
Please make checks payable and mail to:	Horsemen's Council of Illinois (HCI) 3085 Stevenson Dr., Ste. 308 Springfield, IL 62705