ACRL Diversity Alliance INVOICE

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REMIT TO:ACRL Diversity Alliance Attn: Allison Payne50 E. Huron St. Chicago, IL 60611Fax: (312) 280-2520 Email: apayne@ala.org Telephone: (312) 280-2519

Description AmountACRL Diversity Alliance Annual Fee

$500.00

Total $500.00

QUESTIONS? Please contact Allison Payne at apayne@ala.org or call (312) 280-2519. Thank you!

FOR OFFICE USE: Received:

Processed by:

Process date:

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Notes:

CONTACT INFORMATION: Institution/Company:

Residency Coordinator Name:

Residency Coordinator Title:

Street Address:

City, State, Zip:

Phone:

E-mail Address:

E-mail Address for Diversity Alliance Digital Badge (if different from above):

TERMS Please remit this completed form with payment information or check within 30 days. Confirmation of payment will be sent to you upon receipt. ACRL FED ID# 36-2166947

PAYMENT METHOD: __ Enclosed check payable to, “American Library Association”

__ Visa __ MasterCard __ Amex

Credit Card number:

Name on card:

Expiration date: CVV:

Date: Invoice #: