Application Form

If you experience difficulty submitting the application, please contact Constance Revore

Annual dues $40.00 One full-year membership (12 months) Applicable through August 31, 2018
example: Program Manager, Director, Coordinator
example: AAIII, Analyst II
numeric only - no dashes
Department recharges (not to be charged to government funds) *
example:57201 or 57251 for membership expenses
Campus: SFCMP or Medical Center: SFMED
(optional)
*not required if paying by personal check. Checks payable to: UC Regents Send to UCSF Campus Box 1385 Attention CONSTANCE REVORE