Name:    

Phone:   

AOL Instant Messenger:   

Address:

The following items are optional, but we'd appreciate if you'd fill them out...it would help us tremendously in our efforts to build a better club and to suit your needs and interests.

Major:

Year:

Where are you originally from?:

Resident:          Commuter:

If you are a Resident, which dorm do you live in:

Are you on Co-op right now?:  Yes           No

If Yes, are you still able to become involved in our group
at this time (while on co-op)?:  Yes           No

Are you registered to vote in Philadelphia?:  Yes           No

If not, would you like to register?:  Yes           No

Where did you hear about us?:

What are you looking for in an organization such as ours?:

Thank you - we hope to see you soon!!!