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CentralCoastCalAlumniChapter

2012MembershipForm

Name______________________________________________________________________________

Address_____________________________________________________________________________

City________________________________________State__________ZIP______________________

Telephone___________________________Email___________________________________________

Class__________________Major_________________________________Degree________________

Profession_________________________________________

Enclosedis$___________for_______annualchaptermembership(s)at$25*perperson.
*Annualduesare$10foralumniwhograduatedwithinthelast20years.

Alsoenclosedismy$__________taxdeductibledonationtotheAlumniScholarshipProgram.
(donationsinanyamountaregreatlyappreciated)

Totalenclosed:$__________

PleasemakeyourcheckouttoCCCAC.

Pleasesendthisformandyourannualduespaymentto:

CentralCoastCalAlumniChapter
c/oHalLarson
2325ParklandTerrace
SanLuisObispo,CA93401

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