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Heartland Region Alumni Association Application
Please complete the form and then contact stucker@kckcc.edu to arrange payment.
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* Indicates required question
Name
*
Your answer
Address, City, State, Zip Code
*
Your answer
Phone Number
*
Your answer
Personal Email (not your community college email)
*
Your answer
Community College Attended
*
Your answer
Phi Theta Kappa Chapter
*
Your answer
Transfer Institution (if applicable)
Your answer
Membership Type
*
One Year Student ($15)
Two Year Student ($25)
Two Year Membership with T-Shirt ($30)
One Year Non-Student ($20)
Two Year Non-Student ($40)
Three Year Non-Student ($50)
Five Year Non-Student ($75)
T-shirt Size if purchasing Two Year Membership with Shirt
S
M
L
XL
XXL
XXXL
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