Penn State Chapter of North Texas

Membership Dues and Directory Information

To ensure accurate information in this year's new directory, please complete the following:

Alumni Information

Spouse's Information

Name Name
Address

Complete the following only if your

Spouse attended Penn State
City/Zip
Home Phone
Class Year   Major Class Year   Major
Graduate School Graduate School
Class Year   Major Class Year   Major
Home Town Home Town
Occupation Occupation
Employer Employer
Work Phone Work Phone
Email Address:  

Do you want club updates between newsletter via e-mail?   Yes     No
Do you want your newsletters via Email or hardcopy?   Email     Hardcopy

Dues Payment Enclosed              $ 15.00

Additional Scholarship Donation    $ 

Total Amount Enclosed              $

MAKE CHECKS PAYABLE TO PENN STATE CLUB OF NORTH TEXAS

MAIL TO: Judy Micklow (address can be found in the NTPSU directory or send an e-mail to psu.club@verizon.net)