I.D. Number
(9 Digit Number)

Faculty Staff
Retiree

Annual membership fee:		$35.00
Add to my account:		$_____
Total Amount:		$_____

Make check or money order payable to:
The Pennsylvania State University.

If mailed, send to:
Faculty Staff Club
103 HUB/Robeson Ctr.
University Park PA 16802

This is a gift from ______________________________

Last Name         First     Middle Initial

Campus Address (Retirees should put home address)

City                    State   Zip Code

Phone Number        Department/College

Club Member Signature            Date

Automatic Membership Renewal

Yearly dues will automatically be deducted from your account balance unless you note otherwise here.