Membership Form

Name: ____________________________________________________________Date __________________

Preferred Address: _________________________________________________________________________

City: ____________________________________State: _____________________Zip:___________________

Home Phone: _________________________________Work Phone:_________________________________

Email: _____________________________________________________Year Graduated: ________________

£ Annual Dues: ($35) £ Stevens Alumni House Donation: ________

£ Lifetime Membership: ($250) £ Stevens Brick Paver *($125): _______

£ Payment on Life Membership $________ ($50 payments for 5 consecutive years, may be paid off early)

£ Alumni Scholarship Fund Donation: ______ £ Alumni Operation Fund Donation: ______

Total Amount $_________________

Please make checks payable to USAO Alumni Association, Inc.
Method of Payment: £ Check/Money Order £ Cash £ Visa £ Mastercard £ Discover £ American Express

Account#_____________________________________ Verification Code:____________ (if available)

Name:______________________________ (as it appears on card) Exp. Date:___________

Signature:_______________________________

Print and mail this form to: USAO Office of Alumni Development; 1727 West Alabama | USAO Box 82156;
Chickasha, Oklahoma 73018-5322 For more information, please call (405) 574-1290 or 1-800-933-8726 ext. 1290.
The USAO Alumni Association is a non-profit organization. Your gifts (excluding membership dues) are tax deductible. *All proceeds from the Brick Paver Program will provide funds for the renovation of the Stevens Alumni House. After the House is established, proceeds from the Brick Paver Program will provide upgrades and enhancements for the home’s interior.