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Lifetime Membership Application Form

Date ______________________________________

I have reached the age of (65 years) (70 years) (75 years) (80 years) (delete as appropriate) , have

paid annual membership dues for a minimum of 5 years, and hereby apply for Lifetime Membership in

the Emeritus Association and enclose a single payment of $_______________ which will entitle me to

membership for the rest of my life, without any additional fee payments.

_____________________________________________________________________  (Signature)

Applicable Lifetime Membership Fee

At age of 65 - 69 years $ 240
At age of 70 - 75 years $ 200
At age of 76 - 79 years $ 170
At age 80 and above    $ 140

Name _________________________________________________________________________

Address _______________________________________________________________________

______________________________________________________________________________

Telephone __________________________________________________________________

FAX _______________________________________________________________________

e-mail address _______________________________________________________________