| _______________________________________ | _______ | __________ | |
| Name | Class Year | Maggot # | |
| _____________________________________________________________________ | |||
| Street Address | |||
| _____________________________________________________________________ | |||
| _______________________________________ | _____ | __________ | |
| City | State | Zip Code | |
| _______________________________________ | |||
| Telephone Number | |||
| http://___________________________________ | ______________________ | ||
| Web Site | E-mail Address | ||
| _________________________________________ | ______________________ | ||
| Instant Messaging Service | Instant Message Address | ||
Please allocate my donation to Nu Alpha Phi as indicated: | |||
| $__________ | 2007 Dues ($10/yr) | ||
| $__________ | Back Dues | ||
| $__________ | Wash Fund | ||
| $__________ | General Fund | ||
| $__________ | Nu Alpha Phi Memorial Scholarship Fund, in the name of: | ||
____________________________________________ Write a separate check for Scholarship Fund donations to receive a prompt and proper IRS receipt from Pomona College. Scholarship Fund donations count toward alumni gifts, class gifts, and membership in the Associates, Torchbearers, etc. | |||