Student Chapter Membership Application Please fill out completely with blue or black ink.Application Date MM slash DD slash YYYY Contact InformationPrefix (dr., lt., etc.)Title Mr. Mrs. Ms. Name First Name Middle Name Last Name Sr., Jr., etc. Email Primary PhoneCell PhoneTwitter @ADDRESSESPermanent home address Street Address City State / Province / Region ZIP / Postal Code Current Address at College Street Address City State / Province / Region ZIP / Postal Code Which address is your primary mailing address? My permanent home address My current college address COLLEGE OR UNIVERSITY Untitled Two Year Program Four Year Program School NameUntitled Associate Bachelors Masters Doctorate Other Degree ProgramGraduation Month/Year MM slash DD slash YYYY Major/MinorConcentration/Specialization (if applicable)Name of Faculty Advisor or Department HeadEmail Address Phone NumberI certify that the information provided is true and hereby apply for annual membership in the NAMC Student Chapter for August 1, through July 31, . If accepted, I agree to abide by the chapter’s Bylaws and Code of Conduct. NAMC Student Chapter for August 1,through July 31,Signature of Student(Required)Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
