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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: 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