St. Louis Alumni Club Membership Form

   Name____________________________________________________________________

   Address__________________________________________________________________

   City_________________________  State_______  Zip_____________

   Day Phone__________________________________

   Evening Phone______________________________

   Email_______________________________________

   $20 Per Family Per Year

   Make Checks payable to: The Ohio State Alumni Club of St. Louis

   Send form and check to:

        Josh Bergman

        333 Atalanta Avenue

        St. Louis, MO 63119