Hostos Community College		Membership Form

Alumni membership

Last Name: Maiden Name:

Fist Name: M.I: S.S. #:

Undergrad Class Year: Degree: Major:

Graduate Class Year: Degree: Major:

Home Address:

Street City State Zip

Telephone: Fax:

Home E-Mail Address:

Your Business or Profession: _____

Your Title:

Name of Firm or Employer:

Business Address:

Street City State Zip

Telephone: Fax:

Business E-Mail Address:

Send mail to: Home Business Exclude My name from list provided to outside organizations.

Hostos Membership Dues: $20

Your dues automatically qualify you for all services and benefits and enable Hostos to strengthen its outreach to alumni and students

BY CHECK:

I enclose $20 for Hostos Membership Dues (make check payable to Hostos Community College Alumni Scholarship fund).

Additional contribution to the Hostos Alumni Scholarship $_________

BY CREDIT CARD:

Please charge (check one) $20 for HCCAA Membership Due plus $________ as an additional HCCAA contribution to:

MasterCard Visa

Number: _____________________________________________ Expires: ____________________________________

Name on Card: ________________________________________

Date: ____________________________________ Signature:______________________________________________

Please complete and return this form to HCC by mail. Or you can fax the complete form to (718) 518-4157.