Membership Renewal Membership Renewal Form Title Mr. Miss Ms Dr. Date*Name* First Last If any of the following information has changed since your last Renewal, please complete accordingly – thanks!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 PhoneEmail Employment Status Currently Employed Retired Date First Employed at PalomarDate Retired from PalomarDepartment/Office at Time of RetirementSpouse/Partner NameSpouse Date of BirthPlease 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 enclosed*Mail 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
