Membership Application
Applicant Information:
Name (Mr./Ms./Mrs./Dr.): _______________________________________________ Birth Date:________________
Preferred Email Address:______________________________________________ Last 4 of SSN:_________
Preferred Mailing Address:______________________________________________________________
NEW PAYMENT
METHOD
AVAILABLE!
SEE BELOW FOR
INFORMATION ON
AUTOMATIC
ANNUAL
RENEWAL!
City:_________________________________ State:__________________ Zip:____________
Home Phone: (_______)_______________________ Cell Phone: (_______)____________________
Spouse Information if applying for Joint Membership:
Name (Mr./Mrs./Ms./Dr.):________________________________________ Last 4 of SSN:_________
Preferred Email Address:______________________________________________________________
Receive a FREE UAB T-shirt with your membership!
Choose your size:
S
M
L
XL
Circle two if you are purchasing a Joint Membership
Alumni Chapters
Membership Options:
Student Membership__________________ $25*
*$5 goes to the NAS Football, Rifle and Bowling Pledge
New Graduate Membership_____________$25*
(Within one year of graduation)
*$5 goes to the NAS Football, Rifle and Bowling Pledge
Junior Membership___________________ $30*
(Alumni 30 years old and younger)
*$5 goes to the NAS Football, Rifle and Bowling Pledge
UAB Employee Membership___________ $45*
*$10 goes to the NAS Football, Rifle and Bowling Pledge
Single Membership___________________ $75*
The UAB National Alumni Society has 63 alumni chapters, including affiliates,
geographic and constituent-based groups. The first chapter is included in your
regular NAS membership. Each additional chapter is $15. Employee, Student,
New Graduate and Junior Memberships are discount memberships and
must contribute $15 to join a chapter. Please see the back of this page for a
complete listing and indicate here if you would like to be a member of a
specific chapter: ________________________________________________
Payment Detail:
Membership Dues:
Additional Chapters:
Parking Pass:
Additional Gift:
Total Amount Due:
$_______
$_______
$_______
$_______ Designation: ________________
$_______
*$25 goes to the NAS Football, Rifle and Bowling Pledge
Payment Information:
Associate Membership________________ $75*
UAB Payroll Deduction: ________________(List Employee ID or Blazer ID)
Check Enclosed: Made payable to UAB National Alumni Society
Charge My Credit Card:
VISA____ MasterCard _____Discover ____American Express____
*$25 goes to the NAS Football, Rifle and Bowling Pledge
Joint Membership____________________ $125*
(Spouses living in the same household)
*$50 goes to the NAS Football, Rifle and Bowling Pledge
Credit Card Number:______________________________________
MBA Alumni Chapter Membership______$125*
Expiration Date: __________________________________________
*$25 goes to the NAS Football, Rifle and Bowling Pledge
Name on card_____________________________________________
Lifetime Membership_________________$600*
Total Amount Paid: ______________________________________
(100% tax deductible)
*$100 goes to the NAS Football, Rifle and Bowling Pledge
For an additional fee of $5, please include a UAB
Campus Parking Pass. (UAB employees, current students and
associate members are not eligible)
Required Car Information:
Make: _____________
Tag #: _____________
Model: ____________
Color: ____________
Year: _____________
A portion of your membership benefits student scholarships, athletic
programs and is tax-deductible.
NEW OPTION!! Sign up for Automatic Annual Renewal! You will
continue to receive your annual benefits package every year without the
added paperwork.
You can contact the NAS at any time to cancel your automatic renewal.
 YES! I would like to sign up for Automatic Annual Renewal.
Alumni Chapters
Accounting
Ambassadors
Anniston, AL
Arts & Sciences
Athletic Alumni
Atlanta, GA
Auburn/Opelika, AL
Black Alumni
Business
Central Alabama
Charlotte, NC
Cullman, AL
Dallas/Ft. Worth, TX
Dothan, AL
Education
Engineering
Gadsden, AL
Greenville, SC
Gulf Coast (Pensacola)
Health Care Management
Honors Program
Houston, TX
Huntsville, AL
Jacksonville, FL
Kingdom of Saudi Arabia (KSA)
MBA
MPA
MSHI
Memphis, TN
Mobile, AL
Montgomery, AL
Multicultural Scholars Program
Nashville, TN
National Capital Region
(Washington, D.C.)
New York
North Mississippi
Nuclear Medicine Technology
Nurse Anesthesia
Nursing
Occupational Therapy
Oneonta, AL
Physical Therapy
Physician Assistants
Psychology
Public Health
Public Relations
Safety Blazers
San Francisco, CA
Social Work
South Florida
St. Clair County, AL
St. Louis, MO
Student Alumni Society
Taiwan, ROC
Theatre
Tuscaloosa, AL
UAB Employee
Walker County, AL
Young Alumni
(30 years old and younger)
Other– Not Listed
(write in on front of form)
First Chapter is free, each additional Chapter is $15.00 (Joint Memberships receive two, free Chapters).
Student Members automatically join the Student Chapter, Employee Members automatically join the Employee Chapter, Junior Members
automatically join the Young Alumni Chapter, and MBA Members automatically join the MBA Chapter at no additional fee. All are eligible
to join additional chapters at a cost of $15.00 per chapter.
Only MBA Alumni can join as a MBA Members.
Other Options
 I would like to take part in the Alumni Admissions Program.  Add my name to the UAB Legislative Network.
Please return application to:
UAB Office of Alumni Affairs
ALUM Building, 1301 10th Avenue South
Birmingham, AL 35294-4555
Phone: 205.934.3555 Fax: 205.934.3926 Web: uab.edu/alumni
Updated 6/2015