COAHOMA JUNIOR/COMMUNITY COLLEGE
ALUMNI ASSOCIATION MEMBERSHIP FORM
MEMBERSHIP CHOICE: _____ ANNUAL ($50) _____LIFE ($250)
Name: ________________________________________________________________________
Name at CJC/CCC (if different): ___________________________________________________
Address: _________________________________________ Apt: __________ Box: _________
City: __________________________________________ State: ________ Zip: _____________
Phone: (home) _________________________________ (cell) ___________________________
Email Address: _________________________________________________________________
Graduated class of ______________________ Non graduate year(s) attended _______________
year year
Major at CJC/CCC: _____________________________________________________________
Extracurricular (football, basketball, band, etc.): ______________________________________
Leadership positions (Miss CJC/CCC, Mr. CJC/CCC, SGA, etc.): ________________________
Have you ever been employed by the CJC/CCC & AHS? _____ Yes _____ No
If yes, what area? _____High School _____ College _____ Workforce Development
If no, please list company name and your job title: _____________________________________
If retired, what do you do? _______________________________________________________
Are you currently affiliated with a Coahoma Alumni Chapter? _____ Yes _____ No
If yes, what chapter and location? __________________________________________________
Any additional information you wish to share? ________________________________________
______________________________________ __________________
Applicant Signature Date
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=9>;/4, 10;, C994, @9;5:4069@, 6/, 104@89, 54<35>59;,regarding the nonE discrimination policies: Michael Houston, Director of Human Resources/Coordinator for 504/ADA, Titl e
IX Compliance Officer, Office #A100, Vivian M. Presley Administration Building, 3240 Friars Point Road, Clarksdale, Mississippi 38614; Phone: (662) 621E 4853, Email:
mhouston@coahomacc.edu
All dues mailed should be paid by money order or personal check only.
Mail to: Coahoma Community College, Office of Alumni Affairs, Attn: Mrs. Rita S. Hanfor, 3240 Friars Point Road, Clarksdale, MS 38614
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