2007-2008 MEMBERSHIP & DIRECTORY DATA FORM

Dues for 2007-2008 (includes mailings and directory):

 

Scholarship Fund* (*Optional - tax deduction if you itemize):

 

Professional Development Project (optional) suggested amount*:

 

Gift in Memory of

 

TOTAL AMOUNT REMITTED:

 

Member Information:

Preferred Prefix or Title (Mr./Mrs./Ms., Rev, The Honorable, etc.):

First Name

Nickname (if any)

Middle Name or Initial

Last Name

Preferred Suffix or Credentials (Esq., III, Ph.D., etc.):

Harvard Attendance and Degrees:

Years:

 - Married/ Other

 - Single

 - Widowed

Widow or widower of Harvard Alum?

 Yes No

Harvard Parent or Grandparent?

 Yes No

Name of Child/Grandchild/Former Spouse:

Spouse/Other:

Preferred Prefix or Title (Mr./Mrs./Ms., Rev, The Honorable, etc.):

First Name

Nickname (if any)

Middle Name or Initial

Last Name

Preferred Suffix or Credentials (Esq., III, Ph.D., etc.):

Widow or widower of Harvard Alum?

 Yes No

Harvard Attendance and Degrees:

Years:

Florida Home Address

Dates:

Thru:

Line-1:

Line-2:

Line-3:

City:

State:

Zip:

Florida Home Telephone:

*(Please use new 941 Area Code if applicable)

Email:

@

Office Address

Do you prefer to recieve mail at this address?

 - Yes   - No

Line-1:

Line-2:

Line-3:

City:

State:

Zip:

Office Telephone:

Second (e.g. "northern") Mailing Address

Dates:

Thru:

Line-1:

Line-2:

Line-3:

City:

State:

Zip:

Alternate Home Telephone:

Committee(s) of Interest

Scholarships

 

Newsletter

 

PR/Publicity

 

Book Awards

 

Directory

 

Schools

 

Officer/Director

 

Membership

 

Music Events

 

Events Reception