Candidate Information:

First name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ MI: _ _

Last Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Mailing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Apt # _ _ _ _ _ _ _

City: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State: _ _  Zip: _ _ _ _ _

Phone Number ( _ _ _ ) _ _ _ - _ _ _ _

E-mail Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Student ID Number (ID card): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Academic Standing: __________________________________

Exams Passed: ______________________________________

                                                               ASC Members            Non-ASC

O  Course P/1                                               $15                         $25
O  Course FM/2                                            $20                         $30
O  Course MLC                                             $20                         $30
O  Course MFE                                             $20                         $30
O  Course C                                                  $25                         $35
 

Total Payment Enclosed: $ ________________

Please make your checks payable to UT Actuarial Student Club
 

Please send an e-mail to the club’s Vice-President, Dalesa Bady at vicepresident.utasc@gmail.com with this form and give the payment to Deby Thomas the Financial Director.