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RETIREES ASSOCIATION LIFE MEMBERSHIP CONTRIBUTION FORM

Enclosed is the applicable life membership fee application. It is understood that this is a non-refundable deferred gift to the ETSURA Endowed Scholarship Fund in the ETSU Foundation. The funds will be invested by the university with the income being used for current expenses of the association until my (our) death at which time it (one half if husband or wife) will be transferred to the Endowed Scholarship Fund. It is understood that any benefit received from ETSURA, the university or its foundation for this contribution will be of nominal value and it is fully deductible for tax purposes in the year paid.


NAME OF MEMBER: __________________________________ NAME OF SPOUSE: ____________________________
 

ADDRESS: (Street) ___________________________________________________________________________________
 

(City) ________________________________________________________________ (State) ______ (ZIP) _____________
 

TELEPHONE: ( _____ ) ______________________ EMAIL: __________________________________________________
 

INDIVIDUAL MEMBERSHIP _____________ $100.00
 

HUSBAND AND WIFE           _____________ $150.00
 

ACCOUNT NO.: Fund: 821410; Org: 79998; Banner Account: 29300; Program: 999; Chart E

Make  check  payable  to  ETSU  and  mail to: 
East Tennessee State University Retirees Association
Office of Human Resources, Box 70564
Johnson City, TN 37614-1707. 
Your check will be your receipt.

 

Mailing Address:  Office of Human Resources
ETSU Box 70564
Johnson City, TN  37614-1707
Telephone:  423-439-5825
Fax:  423-439-8354

Office Hours:  8 a.m. to 4:30 p.m. E.S.T. Monday - Friday
Office Location:  Room 308, Dossett Hall

Return to: http://www.etsu.edu/hr/etsura