Enrollment Form

Membership in the VAN is for one year. If you need a year off, please indicate this in the comments section after completing the name & address sections.

Is the VAN for you?

Name
First:
Middle Initial:
Last:
Nickname:
Maiden Name, if appropriate:
Spouse's Full Name:
Contact Information
Mailing Address:
City:
State/Territory and Zip Code:	Select State AE APO Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Country:
Phone #:
E-mail address
Re-enter E-mail:
Additional Information
Valparaiso University graduation date (undergraduate), if applicable:
Undergraduate Major at VU:
If appropriate, graduate degree, graduate major, college/university where it was attained:
Current Title or Position:
Current Employer or Grad School:
Would you like to be a VAN Liaison with a high school near you? Please list high school & town:
	Comments & suggestions for the VAN:
Thank you for sending in your VAN Enrollment Form! Barb Lieske, Valpo Admission Network Director