s this a directory profile change for a current member? Yes

Name:     Nee:   
e-mail:     Class of Membership: Tri-state (NY,NJ,CT) Non-resident Student  

Address (home):                                                              Address (work/other):
                           

Please mail to Home Work

Telephone (home):                Telephone (work/other):        Fax:
              
            
Industry/Specialization:

Education, Field and Year of Graduation: 

Professional History:

In the New York area since (year)   Birthplace: 

Birthday (month, day): 

Association with Canada:  Citizen Spouse Citizen Friend Other

Mother's Birthplace:           Father's Birthplace:

Spouse's Name:          Spouse's Birthplace: 

Spouse's Address (work/other):                               Spouse's Telephone (work): 
    

Language Proficiency:  

Previous Countries of Residence:

Other interests/activities:

Memberships in other organizations:

Which club activities are you interested in? (select all that apply)
Cultural Events    Social Events    Scholarship    Newsletter Mentor Program
Professional Development    Other:

Please note a club member if known: