INDIVIDUAL
MEMBERSHIP ASSOCIATION DUE
AGREEMENT
Name: ________________________________________________________________
Association Name: ______________________________________________________
Dates of Memembership: ____________________ through _____________________
Annual Association Dues Amount: __________________________________________
I hereby pledge that in return for the payment of my membership in the above listed
association that if I should leave my employement with Fairmont State University
prior to the expiration of my membership, I will reimburse the University for the pro-
rated amount of the individual membership due paid.
Dated this___________ day of _________________, ____________
(date) (month) (year)
____________________________________
Signature
___________________________
Title
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