PSC MEMBERSHIP UPDATE FORM FOR RETIREES

Please print the form.  Complete it and send to:

Professional Staff Congress
61 Broadway, 15th Floor
New York, NY 10006
   ATT:  Diana Rosato/ Membership Coordinator

NAME

First Name __________________________________Middle Name _______________________

Last name ____________________________________________________________________

HOME ADDRESS

Number and street ______________________________________________________________

Town/city _______________________________________State and ZIP ___________________

PHONE

Home Phone _____________________________Office Phone __________________________

COLLEGE THAT EMPLOYED YOU:

College _______________________________________________________________________

Rank/Title ________________________________Department ___________________________

EMAIL