MEMBERSHIP APPLICATION

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Section 1 of 8

Email address

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Membership Year

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2019

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Name

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Address

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Phone number

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Date of birth

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School/Business Affiliation

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Alumni Chapter President Name

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Alumni Chapter President Email Address

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Alumni Chapter HBCUC Representative Name

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Alumni Chapter HBCUC Representative Email Address

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School/Business Affiliation Website

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After section 1

Section 2 of 8

Gender

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Female

Male

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Racial or Ethnic Group

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American Indian/Alaskan

Asian/Pacific Islander

Black/African American

Hispanic/Latino

White/Caucasian

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Military Service

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Yes

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Years of service

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Branch

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