IUSS CAESAR ALUMNI ASSOCIATION MEMBERSHIP APPLICATION
(Print this page for form)

Information provided in this application will be used 
for the sole purpose of the Association Newsletter and 
will not be released to any other organization or activity. 
Approval for use of this information in the Association 
Newsletter is assumed unless you request otherwise.

PLEASE PRINT CLEARLY

NAME: ________________________________________ 
Last First MI Rank/Rate (if applicable)

ADDRESS: ________________________________________ 
Street / Apt. City State Zip

TELEPHONE: Home: ______________________ 
(optional) Business: ____________________

EMAIL ADDRESS: ________________________________

HOME PAGE URL: _______________________________ 
(Both optional)

IUSS SERVICE/AFFILIATION: Location, Dates, Position, etc.

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

ADDITIONAL INFORMATION: Family, current endeavors/employment, nice to know
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
(Use additional page if required)

Mail to:
IUSS/CAESAR ALUMNI ASSOCIATION
N. J. McConnell, DIRECTOR
8930 St Andrews Dr
Chesapeake Beach, MD 20732