Student Member Application

Please fax to: Ted Lloyd

606-622-6274

Name:________________________________

Address:______________________________

_____________________________________

City:_________________________________

State:___________ Zip:_________________

Country:____________________________

School Phone Number:___________________

School Currently Attending:________________

_____________________________________

Year in School:_________________________

Expected Graduation Date:________________

You may contact us at: 606-622-2334 or Fax: 606-622-6274 or email: E-mail Ted Lloyd EasternKentucky Technology Center, 307 Whalin Technology Complex, Eastern Kentucky University, Richmond, KY 40475-3115

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