Central Virginia LSU Alumni Chapter

2008 Membership Application/Renewal

Name:

Address:

City, State, and Zip Code:

Phone Number:

Fax Number:

E-mail address:

LSU Class of (or dates attended LSU):

Interests:

Dues: $ 10 (Individual) ________ $ 15 (Family) ________

Please make checks payable to:

Central Virginia LSU Alumni Chapter

Please return to:

         Central Virginia LSU Alumni Chapter
        12718 Cottage Mill Terrace
         Midlothian, VA 23114