Your Information:
Full Name:                                                                     Date Of Birth:              
        
   
Degree(s) or Certificate(s) Earned:                                   Class Year(s): 
   

Home Phone Number:                             E-mail Address:
         

Mailing Address:


City:                                                      State:                  Zip:
             AL AK AS AZ CA BC MB AB AR CO CT DE DC FM FL GA GU HI ID NC SC TN IL IN IA KS KY LA ME SD ND MH MD MA MI MN MS MO MT NE NV NH VT NJ NY NM MP OH OK OR PW PA PR RI TX UT VI VA WA WV WI WY AP AE AA NA YT SK QC PE ON NS NT NL NB               

Country:

Previous Address (if different than above)

Marital Information
What is your marital status?                   Is your spouse an alumnus?
Married Single Divorced                                         no yes na

Spouse Full Name (Maiden Name if Applicable)

Employer Information
Employer:                                                     Job Title:
         

Business Phone:

Employer Address:                                   Comments/Class Notes:
                

Let us know of any JCSU Clubs, Distinguished Achievements, or any other extra-curricular activities
that you participated in as a JCSU Student. For example: Band, Choir, Miss JCSU, Sororities, Fraternities, etc.