Instructions: You may use the PRINT feature of your Web Browser to create a copy of this form. Mail the completed application to the address above. Do not fax as it contains personal information about your method of payment. By including your signature on this form or by making payment by check, it is understood that you agree to abide to the By-laws, Rules, and Regulations of the Faculty Club.
(Your Middle Name is required if you elect Payroll Deduction for payment of dues)
Spouse/Family Member's Name: ________________________________________
University Title: (please circle one)
E-mail Address: _______________________________________
Office Address: ________________________________________________
Mail Code: _______________________
Home Address: (bills and other information are mailed to your office unless otherwise requested)
Office: (_____) ______________________
Home: (_____) ______________________ (optional)
Members pay a one-time fee of $200 (or $100 for new Faculty/Staff/Alumni/Graduate Students in their first 6 months with the university).
Please Circle One:
Family Membership (allows second card for family member)
Methods of Payment (please circle one)
Dues are billed to each member's account semiannually, in January and July, or prorated if appropriate. Members who electe payroll deduction will have their dues deducted monthly. Please fill out the section below which corresponds to your preferred method of payment.
Monthly Payroll Deduction of dues is available for members on Regental payroll. Please provide the authorization information below and return it along with a check for your first month's dues to the Faculty Club.
AUTHORIZATION TO WITHHOLD MEMBERSHIP DUES
Please type or print:
Last First Middle
I hereby assign to the Ida and Cecil Green Faculty Club from my earnings as an employee of the Regents of the University of California San Diego the amount equal to the monthly membership dues established by the Faculty Club which are to be withheld from my wages until revoked in writing, and I authorize the remittance of that amount to the official designated by the organization. I understand that this deduction is subject to conditions set forth by the Regents.
Signature: _______________________________ Employee No. _____________
After completing, return this form to the Faculty Club, Mail Code 0121
The following information is for office use only:
DEDUCTIONS TO BEGIN FOR THE MONTH OF ________, 19___
Employee No. _____
Element No. 082
Deduction Amount ______
If You Elect Payment by Credit Card: Please return the authorization below to the faculty club with the rest of your membership information.
Billing Authorization: I understand the bills for the Faculty Club fees, dues and /or services are payable upon receipt. I authorize the Faculty Club or its agent to bill the credit card below for any amount as indicated above. I further authorize the club to bill the credit card below, without prior notification, for any amount billed to my club account which I have not paid within 45 days after the billing date. If the credit card authorized below becomes invalid or if I exceed its credit limits, I agree to provide the Club with an alternative valid credit card or otherwise understand that my credit at the Club may be limited. I acknowledge that it is my responsibility to provide the Club with any address changes, and if I fail to do so, my non-receipt of bill(s) does not invalidate any provisions of this authorization. If I do not provide a credit card authorization I understand that my credit at the Club may be limited. The Club will charge 1 ˝ % interest per month on any account balance 60 days old or older. Additionally, the Club will charge a $10 handling fee per month on any account with a balance 60 days old or older. Prompt payment of bills is greatly appreciated.
Please indicate type of charge card:
Card # _____________________________________ Exp. ___________
Name on Card: ______________________________________________
Signature: __________________________________ Date: ___________
If You Select Payment by Check: Please return the following form with your check to the Faculty Club. Please make checks payable to the UCSD Faculty Club
I have enclosed a check for the following to begin my membership at the UCSD Faculty Club:
Initiation Fee $ _____________
Months Dues $ _____________
Dues: $ _____________
Total Amount Enclosed: $ _____________
(858) 534-5719 Fax