The University of Texas Medical Branch

Support Staff Professionals
Membership Form

   

 

 

 

Any questions regarding membership or lunch reservations may be directed to the Membership Chairs 2008-2009, Susie Schexnaider (x26359) & Betty Ince (x22305).
 

Please use tab key to advance between fields; hitting the enter key will submit your form.

Membership Type

Payment Type

Name (Last, First)

Title

Department  

Physical Location            

Phone                      Fax

Mail Route              Email
                                             

Employee Number     

Birth Month        

Birth Day

Fiscal Year

Please send cash/check payment of $10 to the SSP Treasurer, Lori Huepers, at RT 0591.  Memberships will not be processed until payment has been received.

Any questions regarding this web form may be directed to lkusneri@utmb.edu.

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