M.O.S.A.
Mississippi Organization of A.D.N. Student Association

Membership Application
Dues payable in August or January
$20.00 ($15.00 to State/$5.00 to Local)
New Member_____ Renewal_____Two year Member_____ ($40.00)

The following information is very important.  It will be used for mailing.  Please print.

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First name                         Middle initial                           Last name                          S.S.#

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Apt.# or House number

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City                                            State                                               Zip Code

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Phone number (area code)

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Full  name of  School (Do Not Abbreviate)

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Campus & Location

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School City/State
Graduation Date:  (Month)_____________ (Year)__________

Method of payment_________ Check________Money order. 
Make payable to:  M.O.S.A.

Mailing address:  Hinds Community College - N.A.H.C.
                                1750 Chadwick Drive
                                Jackson, MS  39204
                               Att:  Brandi Mullen- MOSA

Optional:  Please complete the following additional questions which will be used for 
statistical purposes.
Date of Birth:  Month_______ Day______ Year________
Race:  Caucasion__Black__Hispanic__Native American__Asian__Other__
Gender:___Male___Female

Membership/MOSA