Prior to completion of this form, please review University Policy 6190, Membership in Organizations,
and follow the procedural instructions as noted on the policy.
Name (Please print): _____________________________________________________________
Department/Unit: ______________________________________________________________
Extension: _________________________ Mailstop: _________________________________
Name of Club: _________________________________________________________________
Duration of Membership (e.g., annual, 5-year, lifetime): __________________________________
Membership Anniversary Date (mm/dd/yr): ________________ Initiation Fees: _____________
Cost: _____________________ per month/year/other:________________________ (circle one)
Type of membership: Individual University
Is this membership transferable? Yes No
Business Purpose of Membership:
I will maintain a detailed log of personal and business use of the club and report that
use quarterly on the Social Club Certification and Activity Log form. I understand that
if I fail to submit this form at the end of each quarter detailing use, the entire value of the
club membership will be treated as taxable compensation to me. (See the Social Club
Certification and Activity Log form to find due dates.)
I elect for the entire value of this membership to be treated as taxable compensation
to me, thus eliminating the recordkeeping requirement.
Employee Signature: _______________________________________ Date:_______________
Dean/Director: ____________________________________________ Date: ______________
President (or designee) or Appropriate Vice President Authorization:
Print Name: _____________________________________________________________
Signature: _______________________________________________________________
Boise State University Rev 2/10
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