Brown Faculty Club
One Magee Street
Providence, RI 02912
(401) 863-3023

The "Friends of Brown" category consists of individuals who are not eligible for membership in a faculty/staff category, nor as alumni of the University, and to whom the Board of Managers extend the privilege of membership.

The undersigned hereby applies for membership as a "Friend of Brown" based on one or more of the following criteria (Please indicate the criteria under which you are requesting membership):

Date	May 24, 2013
Name
Choose those that apply	Service to the University as a Member of the Corporation (Trustee or Fellow) of the University, or Certification by the Vice-President of Development of Brown University that the individuals qualifies as a "Friend of Brown" by reason of their membership in a donor category evidencing the substantial contribution to the financial advancement of the University (donor categories include: Manning Fellows, Nicholas Brown Society, Chancellor's Council, President's Circle, or College Hill Society), or substantially to the financial advancement of the University, or Certification by the President or Provost of Brown University that the individual has contributed directly and substantially to the academic and/or intellectual advancement of the University, or Membership in the Brown Community for Learning in Retirement Sponsors of the Brown Venture Forum
Name of spouse / domestic partner
Home address
Home city
Home state
Home zip
Home telephone
Occupation/Title
Name of Business
Business address
Business city
Business state
Business zip
Business telephone
Mobile telephone
Please mail bills and notices to	Home Business
E-mail