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		Alumnae/i

Office of Alumnae/i and Parent Relations
Ph: (800) 763-7359
Fax: (540) 885-9503
alumnae@mbc.edu

Prospective Student Referral

Fields in red must be completed.

PROSPECT INFORMATION
Student Name (First Middle Last)
Answer this: 3+9= What is this?
Address
City, State Zip
Phone
Student E-mail
Graduation Year
School
Please send the student information on:
Residential College for Women
Virginia Women's Institute for Leadership
Program for the Exceptionally Gifted
Master of Arts in Teaching
Adult Degree Program
ALUMNAE/I INFORMATION
Your Name
Class Yr.
Address
City, State Zip
Home Phone
Your E-mail
Relationship to student
EMPLOYMENT INFORMATION
Job Title
Employer
Work Address
Work City, State, Zip
Work Phone
Work Fax

May we use your name? Yes No

I am a member of: (check all that apply)
Board of Trustees	Parents Council
Advisory Board of Visitors	Faculty/Staff
Alumnae/i Board	Student body
	Class year

Application fee may be waived for students who apply as a result of your referral.