UNIVERSITY CLUB MEMBERSHIP APPLICATION

NAME: _____________________________________  January 1- December 31, 2009 $30.00

SPOUSE: ____________________________________  January 1- December 31, 2009 $30.00

(Complete only if spouse is applying for membership)

NOTE: Mid-year discounted 2009 memberships will only be available to new members.

Renewing members are responsible for the full 2009 membership fee, $30.00 per individual.

TOTAL DUES PAID: $_______

Please complete all information below and return with your payment.

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STREET ADDRESS PHONE: Home and/ or cell phone

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CITY STATE ZIP EMAIL (Announcements are primarily emailed)

CAMPUS ADDRESS

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CAMPUS DEPARTMENT MAILCODE

PLEASE CHECK MEMBERSHIP CLASSIFICATION:

 FACULTY  A/P  CIVIL SERVICE  ALUMNUS  EMERITUS  SPONSOR

Please mail check to: The University Club, Vanessa Sneed, DCE, SIUC MC 6705, Carbondale, IL 62901

MAKE CHECK PAYABLE TO: UNIVERSITY CLUB