LeadingAge Minnesota - Individual Membership Application

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	Individual Membership (Type II)

	This category of membership is for individuals involved in the field of aging services not otherwise eligible through organization memberships.

Contact Information:*

(Mr./Ms.) First & Last Name:
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. Please submit dues to: LeadingAge Minnesota 3001 Broadway Street NE, Suite 300 Minneapolis, MN 55413 membership@leadingagemn.org