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Benefit Eligible Faculty/Staff Membership Application

Summer II 2014 - Summer I 2015 (June 26, 2014 - July 5, 2015)
$270.00 (you only pay taxes)

Membership begins on the first semester day based on the University calendar.


New Renewal

Faculty Staff

Work phone:

I have read and understand all information in the SRC Membership Contract.

IMPORTANT TAX INFORMATION I hereby authorize the payroll department to deduct taxes from my paycheck. I understand this agreement is non-revocable and cannot be refunded for any reason. I understand that $270.00 will be reported as extra income and I will be taxed on this amount.