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						DUES FORM     ____ NEW MEMBER                                                     PLEASE DO NOT PAY IF YOU PAID IN THE FALL     ____CONTINUING MEMBER NAME(S): ______________________________________ ADDRESS: _____________________________________ _______________________________________________ ______________________________________________ TELEPHONE NUMBER:_________________________ EMAIL ADDRESS_______________________ DUES FOR THE ACADEMIC YEAR (2011-2012) :  $10.00 PER PERSON.                                                                                                        PAYMENT ENCLOSED --------------------        WRITE CHECK PAYABLE TO EMERITUS ASSEMBLY, AAUP AND MAIL TO RICHARD P. WURST, TREASURER, 29 DONNEL ROAD, VERNON, CT  06066-2705
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					RESERVATIOM FORM                  Ballard institute Tuesday, 4/17/2012 Please reserve by 4/10/20121                                        NO..___________                                (Admission $5.OO PER PERSON) Wadsworth Atheneum Thursday 5/17/2012                                                                           NO.__________ Please reserve by 5/10/2012 Admission $10.00 per person for non-Atheneum members) Lunches for both of these events are pay as you go.                                                                                                          PAYMENT ENCLOSED  $____________                                                                                                                                                                                                                                                                                                                                         NAME(S): __________________________________________ ADDRESS: _________________________________________ ___________________________________________________ ___________________________________________________ TELEPHONE NUMBER:_______________________ EMAIL ADDRESS:____________________________ WRITE CHECK PAYABLE TO EMERITUS ASSEMBLY, AAUP AND MAIL TO RICHARD P. WURST, TREASURER,  29 DONNEL ROAD, VERNON, CT  06066-2705