Street

Apartment #

City, State and ZIP

Home Phone

Work Phone

E-mail

Date of Birth

Occupation

University Attended/Attending

Major

Year of Graduation/Anticipated Graduation

Are you currently enrolled?
Yes
No

Interests (please mark all that apply):
Social
Sports
Speakers
Israel
Jewish Awareness
On-campus programs (specify campus)
United Jewish Communities
Shabbat Dinners
Community Service
Other

Comments, suggestions, or names/addresses of friends: