ALUMNI INTEREST GROUP MEMBERSHIP PETITION

Alumni Interest Group:

Please Print:

Name: Maiden Name

PSU Class Year: Major: Student #:

Home Address:

Home Telephone Number:

Employer: Occupation: Job Title:

Work Address:

Work Telephone Number: E-mail Address:

Are you interested in being actively involved? o Yes o No (Mailing list only)

If so, please indicate your area of interest: o Interim Board o Programming

o Membership Committee o Social Committee o Mentoring

o Other

Comments, if any:

Signature: Date:

Mail completed form to: