Costco Membership Form – September

Name *

First

Last

I Work For *

Phone

Email *

Driver's License *

Driver's License State of Issuance *

Date of Birth *

Choose One *

Option 1: I'd like to get a new Costco membership. Please deduct $32.50 from my first paycheck in October.
Option 2: I’m already a Gold Star member; please renew my membership and deduct $32.50 from my first paycheck in October.
Option 3: I’m already an Executive member; please renew my membership and deduct $97.50 from my first paycheck in October.

If you are renewing an existing membership established through Kaya HR, please provide your card number and expiration date in the box below.

Cost

$0.00

I authorize Kaya HR to deduct this amount from my first paycheck in October.

Note: You’ll receive a free household member card at the membership desk inside your local Costco!

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