NSU ALUMNI ASSOCIATION MEMBERSHIP APPLICATION   

Name:___________________________________________________ Date:__________________

Address:________________________________________________________________________

City:______________________________ State:________________ Zip:____________________

Telephone: (Home) ____________________ (Work) _____________________ Ext.___________

E-mail:_________________________________________________________________________

Social Security No:____________________________ Date of Birth:________________________

New or Renewal Membership (please mark the areas that apply):

      New

              Renewal (Previous Membership)

›     National  

›     Chapter (Name) ___________________________

›             Recent Grad (within the past 2 years)

Membership Type:

              Regular                  $25 Alumni, Former student

              Associate              $25 Non-Alumni, Friend of NSU

              Life*                       $500

*Life Membership Payment Plan:

›     Full payment         $500 (enclosed)

›             Two year Plan       Year One $250 (enclosed), Year Two $250

›             Three year Plan    Year One $250 (enclosed), Year Two $125, Year Three $125

Replacement Card:            Lost/Stolen           $5  

Did you attend NSU?          ›  Yes    › No        Year(s) at NSU:_____________________   

Major: __________________________________ Graduation Year: __________________

Degree: _________________________________  Certificate: _______________________

If you are interested in organizing/joining a chapter or need additional information regarding  membership, please contact: Office of Alumni Relations Telephone: (757) 823-8135 or 1-(800)-NSU-ALUM   E-mail: alumni@nsu.edu

Please make your check payable to NSUAA. Mail the application & check to: NSUAA, PO Box 12842, Norfolk, VA 23541