DATE ____________
NAME _____________________________________________________________
(Title) (Surname) (First) (Middle)
ADDRESS _____________________________________________________
CITY __________________ STATE ______ ZIP CODE __________
HOME PHONE ______________ BUSINESS PHONE _______________
SPOUSE'S NAME ___________________________________
E-mail: _________________________________________
EDUCATION
HIGHEST DEGREE __________________ DATE AWARDED _______
UNIVERSITY ____________________________________________
NAME UNDER WHICH DEGREE WAS CONFERRED __________________
COMMENTS: _____________________________________________________
_____________________________________________________
SIGNATURE OF APPLICANT ___________________________________
Please print, fill out completely, and return
with $40 Application Fee/First Year Dues to:
The Hellenic University Club of Southern California
PO Box 45581
Los Angeles, CA 90045-0581