UNIVERSITY OF VICTORIA RETIREES ASSOCIATION
Effective April 1, 2023 to March 31, 2024
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*	 [see below]	
This form can be filled online and emailed back to UVRA
*The annual membership fee is $20.00.  A Life membership fee is $160.00. 
Payment Options: Interac e-transfer (instructions supplied upon request). Receiver’s name is UVRA; receiver’s email address is uvra@uvic.ca.
By post to UVRA, R-Hut, UVIC, Box 1700, STN CSC Victoria, BC V8W 2Y2. Or, by campus mail. 
RECEIVED IN OFFICE: ____________    ON DATABASE: ______________________
ML____Date____________________   		BY: _____________________
BK____Date_______________