First Name:
Last Name:
Title:
Department:
Institution/Business Name:

Gender:	Male	Female

Address:
Line 1:
Line 2:
City:
State:		Zip:		-
Phone:	- -
Fax:	- -
E-mail:

Your Institution/Business/Association website URL:

Your specific program/service website URL (if different):

Department Responsibilities:          Select Primary Role Campus Visitor Center Campus Information Center Admissions Campus Tour Guides Relations Department Campus Student Center/Union

Select Additional Roles Campus Visitor Center Campus Information Center Admissions Campus Tour Guides Relations Department Campus Student Center/Union Select Additional Roles Campus Visitor Center Campus Information Center Admissions Campus Tour Guides Relations Department Campus Student Center/Union

Select Additional Roles Campus Visitor Center Campus Information Center Admissions Campus Tour Guides Relations Department Campus Student Center/Union Select Additional Roles Campus Visitor Center Campus Information Center Admissions Campus Tour Guides Relations Department Campus Student Center/Union

If you are renewing an Institutional Membership, please tell us the names of your other member(s):

Note: If this is a new membership, please have each person complete a separate application.

New Members Only: if someone referred you to CIVSA, please tell us their name and institution:
Name	Institution