Please Make Check Payable To:
TCNJ Recreation Services
S.S. #:
________________________ (For Faculty/Staff Payroll Deduction Only)
Spouse Name:______________________ Dependents: __________________________
(If Family Membership) (If Family Membership)
Home
Address:___________________________________________________________
________________________________________________________________________
(City)
(State) (Zip)
Home Phone: ( )_____________________ Work Phone: ( )__________________
Email: ______________________________ License Plate #: _____________________
(Permits for Alumni/Medical Only – Lots #4-6)
Membership Type:
Alumni Individual or Family Year Graduated: ________________ (Submit Copy of Alumni Card)
Faculty/Staff Individual or Faculty/Staff Family
Medical Individual
In case of emergency, contact:______________________Phone: (
)______________
Do you have or have you ever been diagnosed to have: heart disease, heart attack, cardiac surgery, stroke, pacemaker, aneurysm, or angina pectoris?
Yes? (Initial)________________ No? (Initial)_________________
(If YES, your membership will be on hold until you
receive medical clearance)
BILLING:
Membership
Type:___________ Bi-Wkly Deduct. Of:
____________ Cost:__________
# of
Payments: ____________
Individual or Family:
____________ Amount
Received: ______________________
Check/Cash
Date
Received : _________________ Membership # :_________________________
Date
Sent: _________________ Parking Permit #: _______________________
I
agree to allow The College of New Jersey Physical Enhancement Center to deduct
the amount of my membership on
bi-weekly payments of: ___________until paid in full.
Name
(print)___________________________
Signature _________________________
I
acknowledge that I have received and will comply with the rules and regulations
of the TCNJ Physical Enhancement Center and is non-refundable and
non-transferable.