MURA Membership Application
Member Information
Are you registering/paying for yourself or yourself and a spouse/partner?
*
One membership
Two memberships: self and spouse/partner
Member Name:
*
First Name(s)
Middle Name
Last Name
Preferred Name for Name Tag:
Address:
*
Street Address
Street Address 2
City
Please Select
Alabama
Alaska
Arizona
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Delaware
District of Columbia
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Maine
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone Number
Cell Phone
E-mail
*
Membership Category:
*
Retiree
Pre-Retiree
Spouse/Partner
Associate
Membership Term:
*
Lifetime ($100 per person)
Annual ($12.50 per person)
Member Optional Information
Retirement Date:
-
Month
-
Day
Year
Date
Position Type:
Staff
Faculty
Gender:
Female
Male
Prefer not to state
Preferred Pronoun
she/her/hers
he/him/his
they/them/theirs
Member Volunteer Opportunities
I am interested in serving in the following:
Elected or Appointed MURA Board Positions
I am interested in learning more about MURA Committee work (check all that apply):
Programs
Awards
Educational Breakfasts
Communications
Membership
Audit/Finance
Scholarships
Spouse/Partner
Spouse/Partner Information
Spouse/Partner Name:
First Name(s)
Middle Name
Last Name
Spouse/Partner Preferred Name for Name Tag:
Cell Phone:
Email:
Membership Category:
Retiree
Pre-Retiree
Spouse/Partner
Associate
Membership Term:
*
Lifetime ($100 per person)
Annual ($12.50 per person)
Spouse/Partner is not joining MURA
Spouse/Partner Optional Information
Retirement Date:
-
Month
-
Day
Year
Date
Position Type:
Staff
Faculty
Gender:
Female
Male
Prefer not to state
Preferred Pronoun:
she/her/hers
he/him/his
they/them/theirs
I am interested in serving in the following:
Elected or Appointed MURA Board Positions
I am interested in learning more about MURA Committee work (check all that apply):
Programs
Awards
Educational Breakfasts
Communications
Membership
Audit/Finance
Scholarships
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PayPal Account
Membership Payment
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Annual $12.50 per person
How many new annual memberships?
$
12.50
Quantity
0
1
2
Item subtotal:
$
0.00
Lifetime $100 per person
How many new Lifetime memberships?
$
100.00
Quantity
0
1
2
Item subtotal:
$
0.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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