For each applicant, print out this form and fill in the following information:
Date__________________
Your institution_______________________________________________________
Your title (Dr., Ms., Mr.)_______________________________________________
Your first name____________________
Your middle initial______
Your last name ____________________
Your position__________________________________________________
Address at institution____________________________________________
______________________________________________________________
______________________________________________________________
Office phone_(______)________________
Home phone (optional) _(______)________________
Your e-mail address______________________________________________
FAX number _(______)________________
Please check desired membership. (*NOTE: Your Honors Program must have a paid, institutional membership for faculty, staff, or students to qualify for affiliated membership.)
______*Institutional (includes membership for the director) ($50)
______*Faculty or staff at member institution ($20)
______*Student at member institution ($15)
______Non-affiliated individual ($30)
Mail completed form and check to:
Dr. Ross Wheeler
Queens College
Office of Honors and Scholarships
B
Building, Room 310
65-30 Kissena Boulevard
Flushing, NY 11367
(718)
997-5516
FAX: (718) 997-5498
email: rwheeler@qc1.qc.edu
This site is provided by the The Honors College at the University of Maine. If you have any suggestions, questions, or comments about it, please contact Charlie Slavin,
Last updated: Thursday, 05 October 2006 01:16:16 PM -0400