Lifetime Membership Submission Form

Webform

Recipient’s Name (as it should appear in print):

Is this person a currently serving trustee?

Years of service:

College Name:

President’s Name:

Name and Title of Person Submitting Application:

Submitter's Phone Number:

Submitter's E-mail:

Please list any additional information or special notes here:

Is this a gift or a personal membership?

Preferred Mailing Address:

Date on Plaque (Month and Year):