Alumni Association Membership Form

First Name
Middle Name
Last Name
Maiden Name
Address
City
State
Zip
Last four digits of your Social Security #   
Birth Date (MM/DD/YYYY)
Phone Number
Business Phone Number
Email Address
Dates Attended ICC
Occupation
Activities at ICC
Children
Did Children Attend ICC?  Yes  No
Honors
Spouse
Spouse Dates Attended ICC
If Attended ICC, Maiden Name
If Attended ICC, Last Four Digits of SSN
Spouse Birth Date
Spouse Occupation
Spouse Activities at ICC
Other Information.

Membership Dues:

$10 per year per person
$15 per year per couple.
$100 lifetime membership per person.
$150 lifetime membership per couple.

The Association marks its year from October to October.

Membership Type:    Renewal  New

Mail Payment To:

Alumni Office
Itawamba Community College
602 West Hill Street
Fulton, MS 38843