Alumni Association Membership Form

Name: *

Maiden Name: (if applicable)

Degree/Major:

Graduation Year: *

Address: *

City: *

State: *

Zip: *

Phone: *

Email: *

Occupation/Title: *

Birthday: * +

Spouse (if applicable)

Name:

Maiden Name: (if applicable)

Degree/Major:

Graduation Year:

Address:

City:

State:

Zip:

Phone:

Email:

Occupation/Title:

Birthday: +

Children (if applicable)

Name:

Date of Birth: +

Name:

Date of Birth: +

Name:

Date of Birth: +

Select One Membership Dues Option: *

$50 Yearly Single

$75 Yearly Couple

$150 Single Lifetime

$250 Couple Lifetime

Additional Contribution Amount:

Additional Contribution Fund:

*Please note: Yearly membership runs July to June of the following year.

Signature *

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East Mississippi Community College is committed to assuring that the College and its programs are free from discrimination and harassment based upon race, color, ethnicity, sex, pregnancy, religion, national origin, disability, age, sexual orientation, gender identity, genetic information, status as a U.S. veteran, or any other status protected by state or federal law. The following offices have been designated to handle inquiries regarding the non-discrimination policies: Office of the Director of Human Resources 1512 Kemper Street Scooba, Mississippi 39358 662.476.5274 Office of the Dean of Students Golden Triangle Campus Disability Services Coordinator 8731 South Frontage Road Mayhew, MS 39753 662.243.1979 Office of the Dean of Students Scooba Campus Title IX Coordinator 1512 Kemper Street Scooba, Mississippi 39358 662.476.5062