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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California
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Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Kentucky
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Maine
Maryland
Massachusetts
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Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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
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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
Please click one of the PayPal options to complete payment and
submit
the form.
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