membership

Please PRINT THIS PAGE, complete, and return to:
Linda Hammerling, 125 Hitchcock Rd., Southington, CT 06489. 
PLEASE PRINT CLEARLY:

Name:  ______________________________________________________________________________

Address: _____________________________________________________________________________

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Home telephone: ____________________________Work telephone:_____________________________

Employer: __________________________________Title:_______________-______________________

Degree/Year:  _________________________________________________________________________

Email address: ________________________________________________________________________
(NOTE: The e-mail list is maintained locally, so you will not receive club e-mails unless
you provide your e-mail address!  We do not share your contact information with outside
organizations except the UW Alumni Association.

Please check all that apply (make checks payable to "The UW-Madison Alumni Club of CT"):
__  I wish to join as a "friend" of the UW Madison Alumni Club of CT and Western MA." 
     A suggested annual $20 donation is enclosed.
__  I wish to contribute to the scholarship fund.  My donation for $________ is enclosed.
__  I may be interested in planning or running club activities.  Please contact me.
__  I may be interested in reviewing scholarship applications or organizing other activities
__  I may be interested in becoming a club officer.  Please contact me.

Please provide suggestions for club events/activities and indicate your willingness to help organize or participate in new or existing activities.  Suggestions on activity locations are also welcomed.

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Questions?  Feel free to contact club Secretary Jean Oliva at CTBadger83@aol.com or 860-298-6232.