UNI STAT Membership Application

* fields are required

Member Information

*Name:

Anticipated Graduation Year:

*Student ID Number:

Birthdate:

Classification as of Fall '09:

FR   SO   JR   SR   GRAD STUDENT

If you know where you'll be living in the Fall of 2009, please list that address here. If you are unsure of your plans for the fall, please list an address and contact information where you can be reached. (For example, a parent address or permanent address.)

*Address:   
*City: *State: *Zip:

*Phone:  
*E-mail:

Attention Off-Campus Students!

For an additional $7.00, students living off-campus may choose to have their complete membership package, including t-shirt, mailed via USPS.

Yes, I live off-campus, and would like my complete membership package mailed for an additional $7.00 charge. I understand this fee is non-refundable.

No, I live off-campus, but I prefer to pick up my package. I understand that my membership card will be mailed to me, but I will need to pick up the other elements of my membership package. (A pick up notice will be mailed to you.)

*Method of payment (please choose one):

Check
Please print this form and mail to the address below with check payable to the University of Northern Iowa Alumni Association.

UNI Alumni Association
Attn: UNI STAT
1012 W 23rd Street
Cedar Falls, IA 50614-0284

U-Bill:
Student ID Number:

Memberships are valid through May 31, 2010.