Fillable AafsaMEMBERSHIPapplication 08082017

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AafsaMEMBERSHIPapplication 08082017

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WSU AFRICAN-AMERICAN FACULTY AND STAFF ASSOCIATION
MEMBERSHIP APPLICATION
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Annual Membership Dues- $130, members can elect to pay dues Bi-Weekly through payroll deductions or a one
time pledge amount .
Faculty and Staff Information:
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Last First Middle Maiden/Other
Email: ___________________________________Birth Date (mm/dd only):____________________________
Permanent Address__________________________________________________________________________
Phone:______________________________________ Work Phone:___________________________________
Department:_________________________________________ Title:__________________________________
Committee Interests:____________________________________________ 3OHDVHonly FKHFNWZRFRPPLWWHHV
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________________________________________________________________________________
Faculty and Staff Certification and Signature:
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Signature ____________________________________ Date________________________________
For Offic
e Use Only:
Dues Paid _
______
rev 8/2017
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AafsaMEMBERSHIPapplication 08082017

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Completed 1 March 2020

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