Date:_________________ Member Dues: Regular (alumni) -- $12 per year
Associate (family & friends) -- $6 per year
Special (student) -- Free while enrolled full-time as a student
Lifetime -- $200 Transferable upon relocation
(Effective March 2000) Make
check payable to "KSAA Intermountain Region" and mail the completed
application and check to: KSAA Intermountain Region, 1351 Swinton Lane,
Farmington, UT 84025.
For more information, call
Ron Yasukawa at (801) 451-7312; or email an inquiry to
“[email protected]”; or visit the KSAA Intermountain Region web site at
<http://www.geocities.com/ksaaim/indexa.html> .
PLEASE PRINT!
1. Type Membership: Check One: o Regular o Associate o Special o Lifetime
2. Member Name: ______________ _________________ _________________________
First Middle Initial Last
____________________________________
Maiden Name (if applicable)
3. Year
Graduated Kamehameha _____________
4. Home Address:
____________________________________________ Apt. #________
City: ___________________________________
State: ___________ Zip ____________
Phone (Home): (_____) __________________
Home Fax: (_____)
_________________
Home email: ___________________________________________________
5.
Business Address (if applicable):
_______________________________________________________
City:
___________________________________
State: ___________ Zip ____________
Phone (Work): (_____)
_________________ Business Fax:
(_____) _______________
Business
email (if applicable) ________________________________________________
6. Spouse’s Name ______________ __________ __________________________
(if applicable) First Middle Initial Last
- Mahalo and welcome to the KSAA Intermountain Region
Ohana! -
DO NOT WRITE HERE
Paid
:
Date: In DB: Pkt
Sent: Ck #:
(Version
KSAA-IMR1, 1 Mar 2000)