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