New Member Application Form Membership Application Title Mr. Miss Ms Dr. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Employment Status* Currently Employed Retired Date First Employed at Palomar*Date Retired from Palomar*Department/Office at Time of Retirement*Spouse/Partner NamePlease indicate any items below that you Do Not want published in the PACRA Membership Directory. Postal Address Telephone Number Email Address DUES STRUCTURE: Dues and contributions are tax deductible.ANNUAL DUES (MEMBER First-Year is FREE!) (Member) $25 (Spouse) $25 SCHOLARSHIP DONATION (optional)Indicate Amount of Donation*For more accurate accounting, please write two separate checks payable toPalomar College Foundation – PACRAAmount of check enclosedMail to: TOM HUMPHREY, TREASURER-PACRA 1914 ESPLENDIDO AVE VISTA, CA 92084 Sincere thanks, Becky McCluskey, President PACRACommentsThis field is for validation purposes and should be left unchanged. Δ
