WSURA - Forms

WSURA Membership Application

Print and mail to:
Treasurer, WSURA
139 Millett Hall
Wright State University
Dayton, OH 45435

WSURA Membership Type New Renewal
Name:
Date of Birth:
Primary Address:
City:
State:
Zip:
Phone:
E-mail:
Wright State Department at Retirement:
Year of Retirement:
If applicable:
Spouse's Name
Spouse's Department at Retirement:
Spouse's Year of Retirement:
Annual Dues: $10.00 Life Membership: $100.00 (ages 59 and below) $75.00 (ages 60-69) $50.00 (ages 70 and above) Note: Classified employees may deduct $10 from each of these categories. If you and your spouse are both retirees from WSU, use the age of the younger spouse for determining the Lifetime fee. If you have paid the current annual fee and would like to become a Life Member, subtract the annual fee and remit the difference.

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