Alpha Phi Omega, Xi Rho Alumni Association

Registration Form

Name: _________________________________ Graduation Date: _________________

Mailing Address:            ________________________________________

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Telephone # (H): _________________         Telephone # (C): _________________

E-mail: ________________________________________

Brotherhood Information

Pledge Class Name (If Applicable): _________________________________ 

Semester/Year: _____________

Big Brother (If Applicable): __________________________________________________

Pledge Class Honoree (If Applicable): _________________________________________

Pledge Class President: ____________________________________________________

Pledge Master (If Applicable): _______________________________________________

Little Brothers (If Applicable): ________________________________________________

Additional Information

Spouse/Partner/Significant Other (If Applicable): __________________________________

Children (If Applicable): ______________________________________________

Occupation: _______________________________________________________

Any Other News?

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Please mail this completed form to:

Jay Deitchman

5 Factory Street

Maryland, NY 12116

Please make your check payable to "Xi Rho Alumni Association."