Membership Application

Membership Application
Name

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Telephone Number (s):

HomeCell PhoneWork
Home
Cell Phone
Work
Education Institution

Hinds County Agricultural High SchoolUtica Junior CollegeHinds Community College-Utica Campus
Hinds AHS Class of
Utica Junior College Class of
Hinds-Utica Campus Class of
It usually takes about 5-7 business days to receive your membership card.
My Products*
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Lifetime (Emeritus)There is an administration fee included in your dues.
$520.00



Local and National (Alumni)There is an administration fee included in your dues.
$35.00



Associate (Friends & Supporters)There is an administration fee included in your dues.
$35.00



Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.