Application for Membership

Mr./ Ms.

Last name:

First name:

Academic Title:

Nationality:

Number and Street:

City:

State, Zip-Code:

Country:

Phone:

Fax:

E-Mail:

Begin:

End:

Major / Minor:

Degree (M.A., Dipl., etc.):

not a former Heidelberg student

Employer:

Position:

Please assign me my lifelong Heidelberg University Alumni e-mail address. (Only available for former Heidelberg students.)

HAUS has moved from a mandatory membership fee to a voluntary donation. Our expectation is that this change will better suit all our members. Please note that all donations are fully tax deductible. If you would like to support HAUS with a donation, please note the details on the next page.

Referred by:

Website/Internet

Newspaper

Friends/Family

other: