Name

First name:

Middle name:

Last name:

Maiden/former name:

Nickname:

Class year:

Spouse name:

Spouse university:

Spouse class year:

Mailing address

Street address:

City:

State/province:

ZIP code:

Country if not U.S.:

Email and phone

E-mail: *required

Phone: Choose type ofCellHomeWorkFaxOther

Employer name:

Job title:

Employer address:

Employer city:

Employer state/province:

Employer ZIP code:

Employer phone:

Employer e-mail:

As a student, which clubs and organizations you were involved with on campus?

• (e.g. ASWOU, MSU, Math Club, Circle K, Phi Kappa Phi, Rugby Football Club, etc.)

I want to receive these publications:

As an alum, I am interested in: