Governors Club Membership Application

Governors Club Membership Form

Five levels! Choose one. Click here for Giving Level Benefits

		Champions Club ($2,500 and up)

		Black Tie ($1,000 to $2,499)

		Monocle ($500 to $999)

		Top Hat ($250 to $499)

		Red Coat ( $100 to $249)

Note: $50 of your giving level contribution is not tax-deductible.

Name:	(please print as you wish it to appear in publications)


Street: :
City/State/Zip::


Day Phone:
Email:

If you choose not to send the above form electronically, you may mail your completed form and payment directly to the following:

                 Austin Peay State University
                 P. O. Box 4417
                 Clarksville, TN 37044

Checks may be made payable to APSU Govs Club. Thank you for your support of the Austin Peay State Athletic Department.

If you have any questions, please call the University Advancement Office at (931) 221-7024.