MURA Membership Information Form (Payment by check)

Are you registering for yourself or yourself and a spouse/partner?*

SelfSelf and spouse/partner

Member Name:*

First Name(s)Middle Name Last Name

Preferred Name for Name Tag:

Address:*

Street Address

Street Address 2

CityState

Zip Code

Home Phone Number:

Cell Phone:

E-mail:*

Membership Category:*

RetireePre-RetireeSpouse/PartnerAssociate

Membership Term:*

Lifetime ($100 per person)Annual ($12.50 per person)

Retirement Date:

Date

Position Type:

StaffFaculty

Gender:

FemaleMalePrefer not to state

Preferred Pronoun:

she/her/hershe/him/histhey/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):

MURA Membership Information Form (Payment by Check)