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Application for Membership

I hereby submit my registration as a member of Heidelberg Alumni U.S.:

Personal Information

Mr./Ms.

Last name:

First name:

Date of Birth:

Academic Title:

Nationality:

Mailing Address

Number and Street:

City:

State, Zip-Code:

Country:

Phone:

Fax:

E-Mail:

Studies in Heidelberg

Begin:

End:

Major / Minor:

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

not a former Heidelberg student

Profession

Employer:

Position:

Alumni-Email

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

How did you learn about HAUS?

Referred by:

Website/Internet

Newspaper

Friends/Family

other:

I hereby give my permission for my personal data to be stored and utilized by Heidelberg Alumni International in accordance with the German Data Protection Law.

Basic membership is $25.00/year for current students, $50.00/year for all others.

Please make check payable to: Heidelberg University Association

You do not have to fill out the registration again to use paypal.

Requests concerning this page to: Philippe Bayer, Jella Friedrich
April 7th, 2010