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Title:
First Name:
Last Name:
Surname at Harvard
(if different):
Home Address:
Address 2:
City:
State*:
Postal Code:
Country:
Home Phone:
Preferred E-mail Address:
Cell Telephone:
Date of Birth
Gender Male   Female  
Marital Status Married   Single   Widowed  
Spouse's Name
Children's Name(s) and
Date(s) of Birth
* For international addresses please leave this field as "Massachusetts"

Membership Category
Membership Category
you are applying for
(from the lists below)


Employment / Professional Information
Work Title
Firm / Employer Name
Work Address
City, State, Zip Code
Work Telephone
Fax Number
Type of Business or Employment

Educational Information
Undergraduate College
Class of
Years Attended
Degree

Graduate School / University
Class of
Years Attended
Degree
Graduate Department / School
If you are currently a faculty member, Officer, holder of a University appointment, or a member of any board or committee of Harvard/Radcliffe University...
What is your position?
Years of Appointment

How Did You Hear About Us?
How did you hear about us?
Please elaborate on your selection. For example, which advertisement did you see? What event did you attend? What printed material did you read? Who sent the e-mail to which you responded? etc.

Has someone referred you to us? If yes, what is their name?
Please note, a referral is NOT required for membership at The Harvard Club of Boston

Have you ever applied for a membership to the Harvard Club of Boston? Yes   No  
If so, when?

Hobbies or Areas of Interest
Hobbies/Interests 1
Hobbies/Interests 2
Hobbies/Interests 3
Other (include as many as you’d like)

Billing
Send Billing statements to Home   Business  

I hereby apply for membership to the Harvard Club of Boston and authorize the Club to make any necessary background checks to evaluate my application. Upon membership acceptance, I also authorize the Harvard Club of Boston to apply the following Club charges to my credit card:

Credit Card Number
Expiration
Please select Amex   Visa   MasterCard  
CVV Code
Billing Address

The Harvard Club of Boston bills its Members for their dues on a monthly basis, either through automatic credit card payments or by check. If you prefer a different billing cycle please contact one of our membership staff.

After you submit this online application one of our staff will contact you for payment information to activate your membership.

WELCOME TO THE HARVARD CLUB OF BOSTON.


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