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WSURA Affiliate Membership Application

Print and mail completed form with annual dues of $5 to:
Treasurer, WSURA
139 Millett Hall
Wright State University
Dayton, OH 45435

WSURA Affiliate Membership Type
New   Renewal
Name:
Date of Birth:
Spouse's Name:
Date of Birth:
Primary Address:
City:
State:
Zip:
Telephone:
E-mail:
Wright State Department:
Position:
Estimated Year of Retirement:
If with WSU:
Spouse's Department:
Spouse's Position:
Estimated Year of Retirement:

 


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