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Contact Information
First Name
*
Last Name
*
Sex
*
M
F
Birth Date
*
Home Address
*
City, State
*
Zip Code
*
Phone
*
Email
*
Discipline
*
Campus
*
Sponsor
Work Phone
*
Alternate Phone
Signature
*
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Membership Options
Payroll Deduction
*
Yes
Faculty and Associate Dues (Based on 10-Month Cycle):
*
FULL-TIME $21/mo ($210 per year)
PART-TIME $7/mo ($70 per year)
RETIRED $4/mo ($48 per year)
ASSOCIATE (Non-Faculty) $21/mo ($210 per year)
.
Paying by Credit Card
*
Yes
Faculty and Associate Dues (Based on 10-Month Cycle):
*
FULL-TIME $21/mo ($210 per year)
PART-TIME $7/mo ($70 per year)
RETIRED $4/mo ($48 per year)
ASSOCIATE (Non-Faculty) $21/mo ($210 per year)
Please Confirm Annual Amount Due
*
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Credit Card Type
*
Visa
MasterCard
Cardholder Name
*
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Credit Card Number
*
Expiration Date (mm/yy)
*
CSC Code
*
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All credit card transactions are safe.
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