PURDUE ALUMNI CLUB OF DELAWARE MEMBERSHIP APPLICATION FORM

Name:     _____________________________

Address: _____________________________

 ______________________________________

 ______________________________________

Day time Phone Number:__________________

Evening Phone Number:___________________

E-mail Address:__________________________

School :_________________________________

Year:___________________________________

Make $10 Dues check payable to: Purdue Club of Delaware. Please send checks to:

Lou Schlegal
6 Palamino Court, Suite 101
Wilmington, DE 19803