缅北禁地

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Membership Choice*

Annual ($50)

Life ($250)

Couples ($400)

First*

Last Name*

Name at CJC/缅北禁地 (if different)

Mailing Address*

City*

State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Mobile Phone Number

Home Phone Number

Email Address*

Graduated class of (year)

Non graduate year(s) attended

Major at 缅北禁地/CJC

Extracurricular (football, basketball, band, etc.)

Leadership positions (Miss CJC/缅北禁地, Mr. CJC/缅北禁地, SGA, etc.)

Have you ever been employed by CJC/缅北禁地 or AHS?

Yes

No

If yes, what area?

High School

College

Workforce Development

Are you currently affiliated with a Coahoma Alumni Chapter?

Yes

No

If yes, what chapter and location

Any additional information you wish to share?

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