| Member Card Number: |
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| 10-digit number on the backside of member card |
| Prefix: |
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| First Name: |
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| Middle Name: |
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| Last Name: |
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| Suffix: |
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| Date of Birth: |
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MM/DD/YYYY
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| Email: |
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| Spouse/Partner Name: |
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| Name while at SDSU: |
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| First Degree: |
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| College: |
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| First Class Year: |
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| Second Degree: |
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| College: |
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| Second Class Year |
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| Choose Affiliation: |
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| Home Address 1: |
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| Home Address 2: |
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| City: |
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| State: |
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| Zip: |
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| Country: |
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| Phone Number: |
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| Company Name: |
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| Business Address 1: |
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| Business Address 2: |
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| City: |
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| State: |
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| Zip: |
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| Country: |
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| Preferred Mailing Address: |
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