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	Associate Organization Membership - this category is for an organization involved in the field of older adult services that shares the values of LeadingAge Minnesota but is not eligible through another category.

Organization & Primary Contact Information:*

Organization/Company:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Primary Contact (Mr./Mrs) First & Last Name:
Primary Contact Title:
Primary Contact Phone:
Primary Contact Email:

Type of Ownership*

If you have a parent corporation/owner other than that listed above, please provide the following:

If you have a management company other than that listed above, please provide the following:

Other Contacts from Your Organization

Dues Contact Name (if different from primary):
Dues Contact Title:
Dues Contact Email:
Directory Update Contact Name (if different from primary):
Directory Update Contact Title:
Directory Update Contact Email:

Please list a team member you wish to receive communications from LeadingAge Minnesota:

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

	About Your Organization

8.	Describe your organizations services:

Registrations held by this building:

Home Management Services

	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.

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