Noble Center Membership Application – Oklahoma Panhandle State University

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Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Membership Type(Required)

Individual 6 Month – $150.00

Individual Year – $250.00

Family 6 Month – $250.00

Family Year – $450.00

Public Service Membership – $75.00 (individual must be verified before membership can be processed)

Public Service Family- $150 (Good for 1 year)

Family Memberships(Required)

Please list all members to be included. Children under 18 and parents are eligible; no additional family members may be included.

Family member name

Parent or Child

Age

Alumni Life Membership Code

Alumni life members are eligible for a 25% discount after verification of their Alumni Life Membership Code, “firstinitial.lastname25.”

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

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