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		Please print this form and mail to the address shown at the bottom Please do not send any payment information through FAX.  The payment cannot be processed in this manner. 2007-2008 Membership Payment Form (Right to Privacy Laws prohibit release of information on this form.) Name: _________________________________________________     (Last)                                        (First)    Florida Phone: __________________  Out-of-State Phone:______________ Florida Address: ________________________________________________ Florida City: ___________________ Zip: _______________ Out-of-State Address: ________________________________________________ Out-of-State City/State/Zip: ________________________________________________ E-mail Address: ________________________________________________ Date: _____________________________________________ Enrollment Fees         Fall, Winter, Spring each course                        $65                                   or          Member Unlimited       (full year unlimited courses)                              $395 ___ I wish to make a contribution to the Academy for Lifelong Learning Fund at the USF Foundation (This contribution is tax deductible to the extent of the law and is used solely for the betterment of the USF Academy for Lifelong Learning) $ ______ Total payment: $ ______    Check here if you do not wish to have your name and address information included in a membership-only directory PAYMENT INFORMATION: ___ Check  ___ Money Order ___ Visa     ___ Mastercard      ___ Discover Card # __________________ Cardholder Name_______________________ Exp. Date _______________ Signature (credit card only) _______________________________________ NOTE: Checks (U.S. dollars drawn on U.S. banks) payable to the UNIVERSITY OF SOUTH FLORIDA. PRINT, FILL OUT, AND RETURN TO: USF Academy for Lifelong Learning,  8350 North Tamiami Trail B-116, Sarasota, FL 34243-2197. OFFICE USE ONLY: EXT. LIRS Receipt # _________________________ Date: _______________ Persons with documented disability requesting reasonable accommodations should contact the Academy for Lifelong Learning at (941) 359-4296 at least 10 working days in advance of the group start date to make arrangements for the accommodation. Persons with hearing or speech impairments should contact the Academy for Lifelong Learning by using the Florida Dual Party Relay System at 1-800-955-8770 (voice) or 1-800-955-8771 (TDD). The University of South Florida is an equal Opportunity/Equal Access/Affirmative Action Institution
		For more information on the USF Academy for Lifelong Learning: Telephone: (941) 359-4296     Email: academy@sar.usf.edu

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