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UCSB Emeriti Association
2021/2022 Academic Year Membership Form and Dues Notice
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Membership Type
*
Regular Member $15
First time member (no dues)
Regular member, age 85+ (no dues)
Honorary member (by invitation, no dues)
UC Campus & Department from which you retired:
*
Your answer
Year When You Retired
*
Your answer
Academic Title When You Retired (e.g. "Professor")
*
Your answer
Spouse/Partner's Name (if not applicable, please put N/A)
*
Your answer
Phone Number
*
Your answer
Preferred Email Address
*
Your answer
Postal Address
Street Address
*
Your answer
Apt, Suite, Building, Floor, etc.
Your answer
City
*
Your answer
State
*
Your answer
Country
*
Your answer
Zip Code
*
Your answer
A copy of your responses will be emailed to the address you provided.
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