UNIVERSITY OF ARKANSAS OF PINE BLUFF/ AM&N

NATIONAL ALUMNI ASSOCIATION

DETROIT CHAPTER

MEMBERSHIP APPLICATION

NAME:__________________________________________DATE:___________

ADDRESS:_______________________________________________________

CITY:____________________STATE:___________________ZIP:___________

PHONE (Home): ______________________(Cell): _______________________

E-MAIL ADDRESS: ________________________________________________________________

RECRUITED BY: ________________________________________________________________

___RENEWAL MEMBERSHIP ___NEW MEMBERSHIP

Year Graduated:_____________ Degree:______________________

Are you a Member of the UAPB National Alumni Association?
Yes No

Greek Affiliation: ________________ Football Team/etc._________________

Employee Information

Employee Name_________________________ Job Title_______________

Street: _________________________ City _________________State _______

Zip Code: ________________ Business Phone: ________________________

Executive Office Only (Local Dues $50)

Membership Chairperson______ Secretary___________ Treasurer________

Dues collected ____________________________Date ___________________