Elizabeth City State University
National Alumni Association, Incorporated
Membership Application
Check your membership type:
General/ Annual: $30
Individual /Life: $400
Married Couple/ Life: $720
Please type or print all information:
First Name__________________________ Middle Name________________________ Last Name ______________________
Street Address/PO Box________________________________________________________________________________________
City_____________________________________ State____________________________________ Zip code____________________
Telephone # _________________________Cell ___________________________ Email ___________________________________
Year of Graduation__________ Degree(s) _______________________ Major(s) __________________________________
If you did not graduate from ECSU, note year(s) of attendance ___________________________________________
If you did not attend ECSU, state your affiliation ___________________________________________________________
Chapter Affiliation (if applicable) ___________________________________ Region ___________________________________________
Amount Enclosed _____________________________ Date of Application__________________________________
Payment Methods:
Check or Money Order, payable to ECSU NAA, Inc.
Credit Card Information: _____VISA _____MasterCard _____American Express _____Other
Name of the Card _________________________________________________________________________________________________________
Name on the Credit Card _________________________________________________________________________________________________
Credit Card Number _____________________________________________________ Expiration Date _____________________________
Billing Address (if different from above)
Street_______________________________________ City______________________________ State ______________ Zip code_____________
Authorized Signature _____________________________________________ Date___________________________________________
Note: Life membership may be paid in installments with a $100 initial payment for individuals and $250 for couples. The
balance must be paid within one year of the first payment. Associate membership for friends and supporters who did not
graduate from or attend Elizabeth City State University will also be accepted at the same rates designated for alumni.
Please mail your completed form and payment to:
ECSU NAA, Inc., Attn: Membership Chair, 1704 Weeksville Road, CB 977, Elizabeth City, NC 27909
Thank you!
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