Cornell Club of the Greater Capital District Membership Form 2010-2011

Please return your membership information and dues soon!

Are you a new member? Yes No

If this is a renewal, are there any data changes? Yes No

Member 1 _______________________________ Year ___________ School _____________________

Member 2 _______________________________ Year ___________ School _____________________

Home Address ______________________________________________________________________

____________________________________________________ County ________________________

Home Phone _______________________________ Email Address ____________________________

MEMBERSHIP DUES (membership from July 1, 2010 through June 30, 2011)

Cornell Class of: Individual Couple Payment to CCGCD

2010 Free Free

2005 to 2009 $10 $20 $ __________________

2004 and prior $20 $30 $ __________________

Senior Member (65+) $10 $20 $ __________________

Club Sponsor $30 -- $ __________________

Club Patron $50 -- $ __________________

TOTAL MEMBERSHIP DUES $ __________________

SCHOLARSHIPS
I wish to make a contribution to the Greater Capital District Scholarship Fund in the amount of $ _______
and understand that it will be used for local students attending Cornell. Gifts are eligible for matching gift
funds and Cornell Annual Fund credit by submitting a separate check payable to Cornell University.
Please call the Office of Trusts, Estates, and Gift Planning at 1-800-481-1865 if you would like more
information on how you can establish a planned gift to benefit the Club’s Scholarship Fund at Cornell.

ACTIVITIES
I am interested in participating in these Cornell Alumni activities:
Membership Phonathon Admissions Outreach Programming Scholarship
Newsletter Editor Website Development Publicity Golf Outing Club Photographer

YES! I'm interested in subscribing to Cornell Alumni Magazine. Please start my subscription and have
the magazine bill me—just $30 for a one year subscription!

Please make club membership check payable to “Cornell Club of the Greater Capital District” and
mail to Cliff Rohde ● 1230 Sandra Lane ● Niskayuna, NY 12309.