application for campus interest group

to be completed by a designated member authorized to conductbusiness on behalf of the interest group

A)interest group information Print full name of interest group and list affiliations
name of interest group
interest group mission/definition of purpose
affiliated with (check all that apply) / other campuses local organization state wide organization nation wide organization
international organization notaffiliated with any organization or agency
name(s) of affiliate organization(s):
B)active member information / Only UC Davis employees, students, alumni, and spouses of employees or students may be active members.Enter two members authorized to transact business in boxes1 and 2 below.A minimum of 10 active members is required for registration. (UCD P&P §270-08)
name (business representative member)
1. / address / phone
uc davisassociation employee student alumnus spouse ofemployee or student not associated with UC davis
name (business representative member)
2. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
3. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
4. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
5. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
6. / address / phone
ucdavis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
7. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
8. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
9. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
name
10. / address / phone
uc davis association employee student alumnus spouse ofemployee or student not associated with UC davis
c)signatures
by signing below We certify that
a)This application is accurate.
b)Campus Events and Visitor Services will be notified of any changes in the above information.
c)The group will not discriminate based upon race, color, national origin, religion, sex, age, handicap, or sexual orientation.
d)The group will comply with all applicable University policies and procedures.
business representative member 1 / date / business representative member 2 / date

All reservations for group meetings MUST be made through the Campus Events Office: 530-752-2813 (ucd P&P §270-23)

return completed application with $35 registration fee(checks payable to UC Regents) to

CAmpus Events & Visitor Services—442 Memorial Union — 1 Shields Avenue — UC Davis — Davis, CA─ 95616

d)DaFIS CHARGE BACK INFORMATION Use only if registration fee is to be charged to a departmental account
name of Department / seven digit daFIS ACCOUNT NUMBER
FOR CEVS USE ONLY / APPROVED BY / DATE

CEVS CIG1

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