To become a member of the University of Ballarat Alumni Association
and be part of our future,
please print and complete this form and fax to +61 3 5327 9704 or mail to:

Alumni Association
University of Ballarat
P.O. Box 663
Ballarat VIC 3353
Australia

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Personal Details

Please tick one of the following:

Graduate Student No (if known) ________________

Current Staff Member Retired Staff Member

Friend of the University of Ballarat

Mr Mrs Ms Miss Other ____________

Surname: __________________________________________________

Surname at Graduation (if applicable): __________________________

Given Names: _____________________________________

Address: _________________________________________

State: __________ Country: ________________Postcode:__________

Date of Birth:________________________

Telephone:(Home)____________________(Work)___________________

(Mobile)______________________

Facsimile: ____________________

Email: _______________________________________

Spouse (if applicable):_______________________________________

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Course Details

Name of Institution when you attended:
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Campus: __________________

Course/s studied: ___________________________________

Course code: __________________________________

Majors: ______________________________________________

School (eg. School of Business): _____________________________

Year started: ________________Year of Graduation: ____________

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Employment Details

Position Title: ______________________________________________

Occupation: __________________________________________

Employer: ____________________________________________

Employment Address: ___________________________________

State: _____________Country: _________________P/code:_________

Telephone: ______________________ Facsimile: _________________

Email: _______________________________________________

Send Mail to: Home Business

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Staff Details

Staff/Ex staff member at:

Mt Helen Campus Ararat Campus

SMB Campus Stawell Campus

Horsham Campus