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109th Anniversary Dinner - Reservation Request

Indiana Society of Chicago
P.O. Box 46129 • Chicago, Illinois 60646-0129
Tel: (847) 673-2013 • Fax: (847) 674-7366
Email: • Web:

109th Anniversary Dinner - Reservation Request

Saturday, December 6, 2014
Reception & silent auction: 5:00 p.m. (Imperial Ballroom Foyer)
Dinner: 6:15 p.m. (Imperial Ballroom)
Black or white tie


Imperial Ballroom • Fairmont Chicago Hotel
200 North Columbus Drive • Chicago, Illinois 60601
Tel: (312) 565-8000

Dinner tickets are $180 for each Society member and $230 for each non-member guest and $100 for each guest under the age of 35. No refunds will be made for cancellations after December 1, 2014; however, substitutions will be accepted.

For members or guests under 35 years of age, please use the printable form.

If you are a non-member please download and use the printed form.

If you prefer to pay by check, please download and print the registration form here; submit the completed form along with your payment to the address indicated.

Required fields are marked with an asterisk (*).

I. About Me


Billing Address

Please enter the billing address
on file with your credit card company

Shipping Address

Tickets will be mailed to this address
Same as billing address at left


II. About My Guests

Please provide the name of each guest in your party as it should appear in the printed program. Indicate whether or not the guest is a member of the Society and if you'd like the guest to be seated at your table (maximum of 10 people per table). For reservations of more than 10 guests, please download the printed form.

If you are unable to furnish the name of a guest(s) in your party now, please enter "Guest" in the name field, and submit the name by email or fax to (847) 674-7366 before Nov. 24th, in order to have it appear in the printed program.

No. Guest's Name Society Member? Seat at My Table?

III. Summary of Charges

Description Quantity Each Subtotal
Dinner tickets for me and my member guests -- $180.00 --
Dinner tickets for my non-member guests -- $230.00 --
Donation to Indiana Society of Chicago Foundation
If you wish to make an additional, tax-deductible donation to benefit the Indiana Society of Chicago Foundation, Inc. please indicate the amount of your contribution at right
Total   --

IV. Payment Information

Visa, MasterCard or American Express accepted


V. Hotel Reservation

HOTEL RESERVATIONS.  You may call Fairmont Reservations directly at (312) 565-3800 and reference the Indiana Society of Chicago.  Our rate at the Fairmont Hotel Chicago is $226 per night, single or double, or $246 for Deluxe rooms.  Suite rate is $326 if available.

You may fax this form to 847- 674-7366, or scan and email to: