PALOMAR COLLEGE RETIREES'ASSOCIATION (PACRA)
Membership Application Form

 

Today's Date


Please indicate your present Palomar status.

Currently Employed Retired

Mr. Mrs. Miss Ms. Dr.

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

Retiree's Date of Birth


Date first employed at Palomar


Date retired from Palomar


Department/Office at time of retirement


Spouse's Name


Spouse's Date of Birth


Please indicate any of the following that you do not wish to be published in the PACRA Membership Directory

Address           Telephone Number  Email address     

Please choose the highest category of membership possible.  Every contribution will help PACRA meet its
purposes. Dues and contributions are tax deductible.
NOT APPLICABLE - ONE YEAR FREE MEMBERSHIP

Regular $10
Sustaining $15
Contributing $25

Make checks payable to:  Palomar College Foundation - PACRA
 Mail to:
 Robert Larson
 5761 Kensington Place
 Bonsall, CA 92003