Benefits-Eligible Faculty and Staff Membership Form

University Recreation

Benefits-Eligible Faculty and Staff Membership Form

Annual SRC Membership (Valid for one year from date of activation)

$270 (you only pay taxes)

Important tax information
By submitting the form below, I hereby authorize the payroll department to deduct taxes from my paycheck. I understand this agreement is non-revocable and cannot be refunded for any reason. I understand that $270 will be reported as extra income, and I will be taxed on this amount.

Membership type (required)

Affiliation (required)

Name (required)

Last four digits of WIN (required)

Home address

City

State

ZIP code

Home or cellphone

Work phone

Email address (required)

University department (required)

Pay cycle (required)

Pay cycle as defined by payroll and how often you receive your paycheck (biweekly or semimonthly)

Were you referred by somebody?

Referred by

Agree to membership contract (required)

I have read and agree to all information in the Student Recreation Center membership contract below.

Enroll in auto renewal?

Please indicate if you would like your membership auto-renewed each year.

Student Recreation Center membership contract (printable)

University Recreation
�� Michigan University
1903 W Michigan Ave
Kalamazoo MI 49008-5477 USA
Phone (269) 387-4732
Fax (269) 387-3766

Location
2000 Student Recreation Center, Mail Stop 5447

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University Recreation