IIT SINE Membership Form
Date: _________
Name: _________________________________________________
Spouse's Name: ___________________________________________
Home Address: ___________________________________________
City:______________State:_______________Zip: ______________
Telephone: (Res.)__________________(Work) ___________________
e-mail___________________fax ___________________________
IIT Affiliation:___________Year Grad.:______Hostel:______________
Profession:___________Employer/Co.__________________________
Work Address: ____________________________________________
City:__________________State:________________Zip: _________
Membership Type (check one)
____ Life: Dues $150
____ Regular: Dues $35 for 2004-2005
____ Student: Dues $10 for 2004-2005
____ Update / Add to Mailing list
Please check here ____ if you want IIT SINE to exclude you from any sharing of the membership list.
Make checks payable to IIT SINE and mail to:
IIT SINE, 40 Sumac Lane, North Attleboro, MA 02760
Tell a Fellow IITian about us !