Name:_____________________________________________________

Address:___________________________________________________

Phone:_____________________________________________________

Date you became member of PBC:_______________________________

Please provide information below in order for funds to be sent directly to the school to be credited to your account.

Name of School:_____________________________________________

Address:____________________________________________________

ATTN:_____________________________________________________

Phone:_____________________________________________________

Dates expecting to attend:______________________________________

Please provide personal identification in order for school to credit correct account:

Social Security #:____________________________________________

or

School ID number:___________________________________________

Please state future plans including major and after college career plans:

________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10-27-05