Name: ___________________________________________
Address: _________________________________________
_________________________________________________
Phone Number: _______________E-mail: _____________
Major: ___________
Class rank (Freshman, Sophomore, etc): ________________
Status: ____Active Member ____Associate Member ____Emeritus Associate Member
Signature:____________________________ Date:_________________
Offical Use: _____Acceptance Date ________Dues Received
Print off, complete and mail to Linda Jeff, 452 SHP Building, 1705 University Blvd, Birmingham, AL 35294-1212 with a check for $10.