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Name of alumnus/a: 

Maiden Name:

Class year:

Name of spouse:   

Maiden Name:

Is your spouse a SCSU Alumnus/a?     Yes     No

SCSU Class year:

Address:

Home Phone:    

Work Phone:

Home E-mail:

Married on: (mm/dd/yyyy)

Would you like to receive, via e-mail, updates on upcoming alumni social activities in your area and other news on SCSU?
Yes
No

Submitted by:

Phone:

Relationship to alumnus/a: