Central Virginia LSU Alumni Chapter

Membership Application/Renewal

Name:

Address:

City,State, and Zip Code:

Phone Number:

E-mail Address:

LSU Class of (or dates attended LSU):

Interests:

Dues: ___ $15 (Individual) ___ $20 (Family)

Please make checks payable to:

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