East Tennessee State University

Retirees Association (ETSURA)

(Please print in landscape mode.)

ETSU RETIREES ASSOCIATION MEMBERSHIP APPLICATION

Membership is $5 per person per calendar year (January 1 through December 31). Please use this form to renew your membership or become a new Association member. For further information or to check the status of your membership, please call (423) 439-5825.

NAME: (Last) _______________________________ (First) ____________________ (MI) _______ (Title) _______________

SPOUSE'S NAME: (Last) __________________________ (First) ____________________ (MI) _______ (Title) __________

ADDRESS: (Street) ____________________________________________________________________________________

(City) ________________________________________________________________ (State) ______ (ZIP) ______________

TELEPHONE: ( _____ ) ______________________ EMAIL: ___________________________________________________

FORMER STATUS WITH ETSU: _________ FACULTY _________ STAFF

AMOUNT PAID ($5 PER PERSON): ______ $5 __________ $10

ACCOUNT NO.: Fund: 821350; Org: 79990; Banner Account: 29300; Program: 999; Chart: E

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


Back to ETSU Home	Back to ETSURA Home

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: Rooms 308, Dossett Hall