Town & Gown Affiliates of UCLA Annual Membership Dues

RSVP Information

Affiliates Membership Dues
Select	Description	Amount

	Individual Membership - $40 per person
	Family Membership - $60 per household
	Individual Lifetime Membership - $350 per person
	Family Lifetime Membership - $400 per household
	Pay By Check Please specify membership type in the comments box below. The Address where you can send your check will be included in the confirmation email.

Sub-Total:
Tax-Deductible:

Donate to the Affiliates Scholarship Fund

Donate to the Town & Gown Affiliates of UCLA scholarship fund, which is awarded to undergraduate Distinguished Bruin Scholars, community college transfer students, and to students throughout the entire university.

Grand Total:

Tax-Deductible:

Contact Information

Personal

Title:

First name:

Middle name:

Last name:

Suffix:

UCLA graduation year(s):

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:

HomeBusiness

Home telephone:

Business telephone:

E-mail address:

This e-mail is my:

HomeBusiness

Additional Information

	* Additional family member:
	* Additional family member email:
	YES, please include my address, telephone, cell, and e-mail address on the Town & Gown Affiliates membership roster for distribution to Affiliates members. Note: Membership information is confidential and for Affiliates internal use only.

Comments: