Alumni Association Application for Lifetime Membership

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APPLICANT INFORMATION

First Name:

Middle Name:

Last Name:

Maiden Name

Telephone (Day):

Extension:

Telephone (Eve):

Extension:

Address:

Address (Line 1):

Address (Line 2):

City:

State:

Zip Code:

E-Mail Address:

Social Security Number:

J Number:

Date of Birth

Employer:

Employer Address:

Alumni, please tell us:

Graduation Year:

Degree:

Curriculum: (e.g. Nursing)

Educational Achievements:

Other Degrees:

Institutions:

I am interested in serving on the following committees:
Alumni Council Fundraising / Special Events Membership Newsletter

Comments:

Upon payment of your lifetime membership fee of $35, you will be directed to the appropriate College office to obtain your photo I.D. card.

CREDIT CARD INFORMATION

Credit Card	Card Number	Expiration Date	Name (as appears on card)
		/

For more information, please contact:
Tarsha Scovens
Coordinator of Alumni Relations
Community College of Philadelphia
Office of Institutional Advancement
1700 Spring Garden Street-Annex 7th floor
Philadelphia, PA 19130-3991
tscovens@ccp.edu

All information you provide is completely SECURE.