Black Alumni Chapter

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Membership Application and Alumni Profile

Name *

Home Address *

City *

State *

Zip Code *

Phone *

E-Mail *

Are you a graduate of YSU? *

Yes

Graduation Year *

Degree *

Major *

Employer *

Title *

Spouse

If spouse is YSU graduate, what year?

Degree

Number of Children

Names and Ages

What special skills can you bring to the BAC? *

May we publish your name, address, phone and e-mail in a future BAC directory? *

Yes

Comments

Type of Membership: *

(Please check appropriate box)

Regular Member - Graduate of YSU and member of YSU Alumni Society (requires separate YSU Alumni Society application and $30 fee plus $10 BAC annual dues)

Affiliate Member - does not require that you be a graduate of YSU (requires $10 annual BAC dues only)

Required

Please send completed form with $10 check payable to "YSU Black Alumni Chapter" and mail to:

YSU Black Alumni Chapter
c/o Arlene Floyd
Office of Associate Degree and Tech Prep Programs
Youngstown State University
One University Plaza, Tod 301
Youngstown, OH 44504

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