VIRGINIAS COLLEGIATE
HONORS COUNCIL
Annual Dues Form
Calendar Year 2005
Mail to:
A.
F. Conway
Secretary/Treasurer, VCHC
Honors Program, Randolph-Macon College
P. O. Box 5005
Ashland, VA 23005-5505
Call
804-752-3720 or email aconway@rmc.edu with questions.
Checks should be made payable to VCHC. (Federal Tax ID# 54-1345506)
Institutional [ ] $35.00
Individual (faculty) [ ] $10.00 each Name ___________________________ email __________________
Name ___________________________ email __________________
Name ___________________________ email __________________
Individual (students) [ ] $10.00 each Name ___________________________ email __________________
Name ___________________________ email __________________
Name ___________________________ email __________________
Name ___________________________ email __________________
Name ___________________________ email __________________
Total enclosed:
____________
College/University__________________________________________________
Address:__________________________________________________________
__________________________________________________________
Honors
Program Director/Contact Person:________________________________
Tel._____________________
Position_____________________________