Name __________________________________________

Complete the following only if you are a new member or if you wish to change any information in our current directory.

Address______________________________________

Phone ________________________________________

Email _________________________________________

Former occupation ______________________________________________

Current activities_________________________________

Interests________________________________________

Annual dues enclosed:

________ $25 individual membership

________ $40 couples membership

_______ Check (payable to Syracuse University) _______ Visa
_______ MasterCard
Card # ______________________
Exp. Date ____________________

Signature ______________________________________

Please return to:

Institute for Retired Professionals
700 University Ave.
Syracuse, NY 13244