Name:

Partner's name:

Address:

City: State/Province: Postal Code:

E-mail:

Would you like to be included in an e-mail group which provides
updates on campus and Caucus events? Yes No

Webpage:

If we create links from the Caucus website, shall we include your webpage? Yes No

Home phone: Work phone: Fax:

Allegheny class: Major/minor:

Graduate work:
Degree:From/Year:
Degree:From/Year:

Occupation: Employer:

You can use my name for: Yes No - a directory distributed to the caucus membership. Yes No - Allegheny lesbigay students wanting career advise or city information. Yes No - the Allegheny Alumni Office for mailing purposes only. Yes No - the Caucus newsletter. Full First - In the newsletter, should we use your FULL name or FIRST name and last initial? If you select either of the options below, that will negate any 'yes' answers from the above list. No Yes - ONLY the Caucus steering committee. No Yes - ONLY the Caucus steering committee and a member starting a local chapter in my city/area.

Comments, Questions, Ideas: