UNIVERSITY OF VICTORIA RETIREES ASSOCIATION
Effective April 1, 2024 to March 31, 2025

☐ Annual Membership - $30.00
☐ Two-Year Membership - $55.00
☐ Three-Year Membership - $80.00
☐ Life membership - $160.00

First Name		
Last Name	 	
Street Address	 	
City		
Province	 	
Postal Code	 	
Spouse Name	 	
Phone number 	 	
Date Joined	  dd-mon-yyyy	
Date of Birth	  dd-mon-yyyy	
Group Type	__ faculty / __ staff  	
Email Address	 	
Department	 	
University 	 	
Member Status	__  Life / __ Annual 	
Amount enclosed	 	
The annual membership fee $30.00 will be reduced to $15.00 from October 1, 2024 to March 31, 2025.
For payment, we accept INTERAC e-transfer. If you select this option, note that UVRA has arranged with the bank to have Interac e-transfers deposited directly into UVRA’s bank account, so you will be asked, on the e-transfer page, to give our email address (uvra@uvic.ca) and accept this arrangement.
If you prefer to pay by cheque, please make your cheque payable to UVic Retirees Association, and mail it to: UVic Retirees Association, University of Victoria, PO Box 1700 STN CSC, Victoria BC, V8W 2Y2.
RECEIVED IN OFFICE: ____________    ON DATABASE: ______________________
ML____Date____________________   		BY: _____________________
BK____Date_______________