Last name:   First name:   Middle name:

Address:    City :   Zip#:

Telephone#:      Best time to call:

Social Security#:        

Student ID#:

Major :

Birth Date:

Type of Membership: Initial          Continuing         Temporary

First Semester of Membership:

Special  Interests:

PLEASE  FILL  IN  ALL  AREAS  FOR  CONSIDERATION!

• Send a copy of your transcript or grade card (from last semester) and a check or money order for $20.00 (non refundable) for the membership dues (no cash accepted)  to the address given below.

• If you do not fulfill these requirements you will lose your privileges and your membership may be jeopardised.