Personal Information Name * First Last * Last Phone Number * Email Date of Birth * Name to print on badge * Marital Status * Married Single Widower Spouse/Partner Home Address Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Alternate Address (summer, winter, vacation, 2nd home) Alt Address Alt Address Line 2 Alt City Alt State AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Alt Postal Code Emergency Contacts 1st Contact Name (primary) * 1st Contact Phone * 2nd Contact Name 2nd Contact Phone 3rd Contact Name 3rd Contact Phone Education 1st College/University * 1st Degree * 1st Degree Year * 2nd College/University 2nd Degree 2nd Degree Year 3rd College/University 3rd Degree 3rd Degree Year 4th College/University 4th Degree 4th Degree Year Memberships (Fraternities, Sororities, Professional Groups, etc) 1st Membership 2nd Membership 3rd Membership 4th Membership Profession/Career 1st Profession * 2nd Profession 3rd Profession Sponsors (two are required) 1st Sponsor * 2nd Sponsor * Miscellaneous Comments (Outstanding achievements, career path, etc.) How did you learn about the University Club * from a member from a friend from the website from seeing the building other Other Source If you are human, leave this field blank.
