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Governors State Alumni Association Membership Form

Alumni Name:  

Name on Credit Card if different:

Home Address:


ZIP Code:  


Phone Type:  


Company Name:


Company Address:

My Employer may match this gift:  

 Select your membership category as designated below:

$ Annual Premium Membership ($50.00 minimum)

$ Life Membership ($650.00)

I would like to make an additional donation to support students scholarships:

$ Alumni Association Scholarship Honoring Rosemary Hulett

$ Freshman Scholarships

Total donation  $

Please make my gift Anonymous

 Any questions please call (708) 534-7892. Thank you.

Please Note that you must click Submit instead of using the enter key. You will be taken to the GSU Foundation secure donation page to enter your credit card information.