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
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District of Columbia
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Virgin Islands
Virginia
Washington
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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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Annual $12.50 per person
Lifetime $100 per person
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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
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the form.
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