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Click Here MEMBERSHIP APPLICATION
NAME (If Applicable, Include Maiden Name):____________________________________
HM MAILING ADDR:___________________________________________________________
Street/P.O. Box City State/Zipcode
PHONE (Include Area Codes): Hm/Cell: (___) ____________Work: (___) _____________
EMAIL ADDRESS: ________________________________________________________________
UNIVERSITY DEMOGRAPHIC DATA:
Class or Graduation Date (Month/Year): _____ / _____ Major:
Degree Earned at PVAMU: [ ]BA[ ]BS[ ]MA[ ]MS[ ]MBA[ ]PhD
ALUMNI CHAPTER AFFILIATION (If applicable):
F E E D E S I G N A T I O N
(Check applicable spaces and supply required information)
| Membership Category | Payment Method |
| _____ANNUAL MEMBERSHIP: $60, ea | (___) Check, Money Order, Cashier’s Check |
| Valid: September 01, 2007 to August 31, 2008 | (___) American Express |
| | (___) Visa (13 or 16 digits required) |
| _____LIFE MEMBERSHIP: $500, ea | (___) MasterCard (16 digits required) |
| Submit $100 with application to initiate the | (___) Discover Card# |
installment plan (see note below) Card #: _______________________________________
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_____ASSOCIATE MEMBERSHIP: $30, ea Expiration Date: _______/_______
Available only to non-PV Graduates; Credit Card Authorization
Valid: 09/01/2007 to 08/31/2008 Signature:_____________________________________
Make check, money order or cashier’s check payable to: PVAMU National Alumni Association
Mail to address indicated in the heading.
IMPORTANT NOTE: **This $30, annual membership rate for FIRST time members of NAA has expired. Initital rate for 1st time graduate is free when application is filled out and returned to NAA within 12 months of initial degree from PVAMU, after 12 months the rate will revert to $60, per person.
Life Membership installment accounts must be paid in full by August 31 of the fiscal year in which payments start (5 payments @ $100 minimum, each).
OFFICE USE ONLY: (Stamped Date of Receipt)
