ODU ACM Application Form


Date: ____________________________________

Name: ____________________________________________________________

ODU CS login: ____________________
(last known CS login for alumni.. current login for current students.. 
NOT OCCS/MIDAS login)

Preferred contact e-mail address: ________________________________
(we will sign you up for our listserv unless you indicate otherwise)

MIDAS username/ODU e-mail address (OCCS): ______________@odu.edu
(current students only, this is for the purpose of maintaining our 
roster of members with the Office of Student Activities and Leadership)

Phone number: (______) ______-________
(preferably local)


Method of payment: (please circle one)

		                 Check

		                 Cash (CS office only please!)



Dues are: (please circle your current status)

	Undergraduate	$10/Year

	Graduate	$10/Year

	Alumnus/Alumna	$30/Year

	Faculty/Staff	$10/Year

	Xsys		$30/Year 




Please send with payment - made out to ODU ACM - to:

Old Dominion University
Department of Computer Science
Engineering & Computational Sciences Bldg.
4700 Elkhorn Ave. 
Suite 3300 
Norfolk, VA 23529-0162
Attn: ACM Dues 


or drop off in person to Phyllis Woods, 3300 Engineering & Computational Sciences Bldg.


This form must be completed in full in order to be processed.  Thank you!

Revised 2/2007