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Gold Shield Annual Membership Dues
(July 1, 2024 - June 30, 2025)


Required fields are indicated with an asterisk (*).
RSVP Information
Membership Type

Please select the one that applies.
SelectDescriptionAmount
Active Membership - $100
Associate Membership - $100
Sustaining Membership - $100
Non-Resident Membership - $50
Sub-Total:
Tax-Deductible:
   

Grand Total:
Tax-Deductible:
 
Contact Information   

Personal
Title:
 
* First name:  
  Middle name:
* Last name:  
  Suffix:
   I am making this gift as a proxy for my organization/company, which should be recognized as the legal donor

Contact Information
* Street:  
 
U.S. Addresses  
*   City, State, Zip:
 
 
 
Non-U.S. Addresses  
  Non-U.S. City/County
  or Province/Postal Code: 		 
  Country:
 
* This address is my:  
* Home telephone:    
Business telephone:  

* E-mail address:  
* This e-mail is my:  

Payment
Payment method:
Additional Information
 
Comments: 

     



If you have any questions about this donation, please

For questions about your Gold Shield Membership, please contact Gold Shield Dues Chair at GoldShieldDues@gmail.com.
Find out about the security features of this web page that protect your account information.

Questions? Please contact Karen McClain at kmcclain@support.ucla.edu
Click here to view privacy policy and disclosure statements to prospective donors.
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