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 __________________
NAME OF SPONSORING MEMBER _______________________________
SIGNATURE OF APPLICANT ___________________________________
Please print, fill out completely, and return
with $35 Application Fee to:
The Hellenic University Club of Southern California
PO Box 45581
Los Angeles, CA 90045-0581
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