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(*denotes required information)

Name as it appears on Credit Card
*First Name:
Middle Initial:
*Last Name:
Maiden Name:
*Social Security #:
privacy statement
*Year of Graduation:
-or-   *# of Credits Completed
(minimum 30 credits)

Billing Address
Matching Gift Program
(employer matches your donation)
Job Title :
Employer Address:
Business Phone:
(if applicable)
*I wish to join the QCC Alumni Association or renew membership:
Free (new graduate)
*Must apply within the first year of graduation
$25 regular membership
$100 associate membership

$125 regular membership + one associate membership

Payment Information :
*Card Type:
*Card Number:
*CV V Number:
*Card Expiration:
Additional Contributions :
I would like to make an additional contribution to the Queensborough Community College Fund for Special Projects and Scholarships
Additional Contribution:
Other ($25 or more)
I would like to participate in the College’s special project to raise funds and become a part of its history by purchasing a brick inscribed with my name and incorporated into the “Alumni Walk” on campus. Please send me a Brick Reservation Form.