Last Name: First Name: Middle Initial: Jr./Sr.:
Email: Home Phone: - - Cell Phone: - -
Address Line 1: Address Line 2:
City, State and Zip: c/o (if applicable)
Are you a Criminal Justice Major? Yes No Other Major Minor Full-time Student Part-time
Are you interested in: Check All That Apply Being added to our events email list Club membership Alpha Phi Sigma membership
What year of school are you in? Freshman Sophomore Junior Senior Graduate Student Future Student Alumni/Graduated Instructor Other If other, please specify:
How did you hear about us? Student Instructor Class Announcement Bulletin Board Our Website Membership Renewal Other If other, please specify:
Please submit suggestions for club activities which interest you:
Official Use Only - Payment of Membership Dues Date: Amount: Officer Signature:
Cash: Check Number: Member Signature:
SIUE Criminal Justice Club - Receipt for Membership Dues Date: Amount: Officer Signature:
Membership dues are $15.00 per member per academic year. Dues are non-refundable.