Southern Illinois University Edwardsville
Criminal Justice Club
Membership Application

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?

If other, please specify:

How did you hear about us?

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:

Cash: Check Number: Member Signature:

Membership dues are $15.00 per member per academic year.
Dues are non-refundable.