LeadingAge Minnesota - Faculty Membership Application

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	Faculty Membership

	This category of membership is for faculty of colleges and universities whose primary focus is related to aging issues, healthcare administration, gerontology or occupations serving the field of older adult services.

Contact Information:*

(Mr./Ms.) First & Last Name:
Name of College or University:
Address:
City, State, Zip:
Phone:
Email:

2.	How did you hear about LeadingAge Minnesota and what are your primary interests in membership?

	I understand that membership is conditional upon approval by the LeadingAge Minnesota Board of Directors and that before becoming a member I must remit the necessary dues.

3.	Electronic Signature* (Please type in your name)

	This category of membership provides full member benefits, excluding the ability to vote, hold office or serve as a Director. Questions Contact: LeadingAge Minnesota 3001 Broadway Street NE, Suite 300 Minneapolis, MN 55413 651.645.0002 (FAX) membership@leadingagemn.org