Alumni card request form

Application Form for U of T Alumni Card Please print this page, then fill in the form and fax it to 416-971-3131 Given Name_______________________________________________ Family Name______________________________________________ Mr. / Mrs. / Ms / Miss / Dr. (circle one) Maiden/Former Name (if applicable)____________________________ Student Number (if known) _______________________ Birth Date (dd/mm/yy) /________/________/________/ College/Faculty/Dept.___________________________ Graduation Year____________Fall / Spring (circle one) Degree______________________________________ New Address_________________________________________ Apt.__________ City________________________________________ Province__________________ Postal Code_________ Country_____________________________________ Home Phone___________________________________ E-mail________________________________________ Company____________________________________ Your Title____________________________________ Business Address____________________________________ Suite/Floor_________ City_________________________________________ Province___________________ Postal Code_________ Business Phone________________________________ Fax________________ E-mail____________________ Alternative Contact: o Parents o Other Relative o Friend o Other Name _______________________________________________ Address_____________________________________________ City_____________ Province________ Postal Code___________ Phone_______________________________________________ Effective date of new address information: o Now or /________/________/________/ (dd/mm/yy) PAYMENT A fee of $22.60 ($20 plus HST) will process your permanent alumni identification card. o My cheque for $22.60 (Cdn.) is enclosed, payable to University of Toronto. o VISA o MasterCard o American Express Credit Card Number__________________________________________ Expiry Date (mm/yy) /________/________/ Cardholder Signature _________________________________________