Today's Date:________________

[ ] Yes, I want to join the FIU Alumni Association/COE Alumni Chapter

[ ] Yes, I want to renew my FIU Alumni Association/COE Alumni Chapter membership

Name: Maiden Name:

Social Security Number: Year Graduated:

Degree (i.e. Masters): Field (i.e. Art Ed., English Ed.):

Home Address: E-mail Address:

City/State/Zip: Home Phone:

Company/Work Name: Title/Position:

Address:

City/State/Zip: Work Phone:

Spouse/Joint Member Name: Maiden Name:

Company/Work Name: Position/Title:

Address:

City/State/Zip: Work Phone:

Please select a membership choice and method of payment and mail to :

College of Education, Dean's Office, University Park, EB 320, Miami, FL 33199

[ ]Current Year Graduate *Congratulations! $10/year [ ]Annual $25/year Joint Membership** $40/year

[ ]Panther Membership $125/year [ ]Golden Panther Membership $250/year

[ ]Friends of FIU (non-FIU grads) $50/year [ ]Lifetime Membership*** $400 Lifetime Joint*** $700

*Recent graduate rate applies to alumni who have graduated within the last year

**Joint rates apply to alumni who are married or an alumni and their non-alumni spouse

*** Lifetime dues are deposited into a Lifetime Endowment Account.

Check enclosed made payable to: FIU Alumni Association in the amount of $___________

OR *Charge my VISA MasterCard in the amount of $____________

*Members agree to be annually renewed when they charge Alumni Association dues

Card number:______________________________________ Expiration date: ______________________

Name as it appears on credit card:_____________________________________________________________

Billing address if different from above home address: ______________________________________________

______________________________________________

Signature (required if paying with credit card):________________________________________________

For further information, call FIU-6550