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Contact Information

First Name *

Last Name *

Sex *

Birth Date *

Home Address *

City, State *

Zip Code *

Phone *

Email *

Discipline *

Campus *

Sponsor

Work Phone *

Alternate Phone

Signature * 🛈

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 * 🛈

Credit Card Type *

Cardholder Name * 🛈

Credit Card Number *

Expiration Date (mm/yy) *

CSC Code * 🛈

All credit card transactions are safe.

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