Name: ________________________________

Major: ________________________________

E-mail: ________________________________

Check One: ____ Freshman ____ Sophomore ____ Junior ____ Senior

Permanent Address: _________________________

Permanent City / State / Zip: _______________________

Permanent Phone: ___________________________

Local Address: _________________________

Local City / State / Zip: _______________________

Local Phone: ___________________________

Expected Graduation Date (Mo/Yr): _________

**Send this form with $10.00 membership fee to BGCTM, 124 Life Science Building or give it to Dr. Brahier or Jodi Harbal. This fee includes a one year membership in BGCTM and a one year student membership in OCTM.**