Expense Account Statement

Tidewater Chapter North Carolina A&T Alumni Association MEMBERSHIP APPLICATION Name: Home Address: City/Zip Code: Home Telephone Number: Birthday (Month/Year): Name of Business/Work: Business/Work Address: Telephone: E-mail Address: Class (Year): Committee(s) Interest  Annual Fund  Membership  Other Dues (Check Appropriate Category) Please make check payable to: Tidewater Chapter NCA&T Alumni Assn.  Chapter Member ($35.00)  Associate Member ($25.00)  Athletics  Scholarship  Fundraising  Hospitality Fax: / Year 08-09  Student Recruitment OFFICIAL USE ONLY Amount Received:  Cash  Check Number Name of Person Receiving Dues: Date: P.O. Box 2081 Norfolk, VA 23501-2081