Receive a 25% Discount If You Have 10-19 Consecutive Years of Membership

Retirement Program Application

This benefit applies to members who are completely retired. Membership dues are $138 for current Full, Senior, and Fellow members. Participating members receive a discount on their membership renewal based on consecutive years of membership:

·  Receive a 25% discount if you have 10-19 consecutive years of membership.

·  Receive a 50% discount if you have 20-29 consecutive years of membership.

·  Receive a 100% discount if you have 30+ consecutive years of membership.

Criteria:

·  You must be completely retired from full-time employment. This includes consulting or part-time employment.

·  Discounts apply to basic membership dues for Full members (additional forums or divisions, journals, and additional sections are excluded).

·  For Senior and Fellow members, the program will cover the additional benefit of your choice (one journal -or- one additional section-or- two forums or divisions).

·  You will automatically receive the next discount level when you reach 20 or 30 years of membership.

·  If you would like to add optional benefits, please call ASQ Customer Care.

Retirement Program Application

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Member no. Years of membership

______

Name

______

Address City/State/Zip/Postal code Country

______

Home phone Email Last date of employment

______

Previous employer Industry

I have retired from employment on ______and am not consulting or working part-time.

(month and year)

______
Signature Date

Please select the discount that applies:

□ 25% dues reduction. If your dues are currently $138, please pay $103.50.

□ 50% dues reduction. If your dues are currently $138, please pay $69.00.

□ 100% dues reduction. Your basic membership will be renewed at no charge.

IMPORTANT: If you are applying for a 25% or 50% dues discount, you must submit your payment along with this application to cover the remaining portion of your renewal. Return completed application to ASQ Customer Care. To determine your consecutive years of membership, refer to the “Member Since” date located on your membership card.

Payment Information

□Check enclosed

□Please charge my credit card (MC, VISA, AMEX)

______
Card number Expiration date

______
Name of card holder (print) Signature

If you need to request another membership card or verify your years of membership, please contact ASQ Customer Care by phone at 800-248-1946 (USA and Canada), 001-800-514-1564 (Mexico), or +1-414-272-8575 (all other locations); by fax at 414-272-1734; or by email at .

*Prices subject to change.

Item B0488 Priority Code MBKAF51