Membership Application

ASTHMA NETWORK OF WESTERN MICHIGAN MEMBERSHIP APPLICATION

Asthma Network of West Michigan wishes to maintain current information on all coalition members.  A formal membership application is one method that facilitates complete and accurate data collection related to those who are members.  Membership renewal is requested annually at the May meeting.  Members are eligible to vote on issues after submitting an application and a  membership vote admitting them as a voting member.

Date_______________

Name _________________________________________

Title________________________________________________________________

Affiliation ___________________________________________________________

Address_____________________________________________________________

Phone____________________      Fax #______________________________

E-mail _____________________________________________________________

Application as an individual_____  or  corporate/institutional representative _____

If corporate/institutional representative, please indicate name of corporation/institution___________________________________________________

Is this corporation a sponsor of Asthma Network Of West Michigan?   Yes________     No_________

Would you be interested in serving on the Asthma Network Of West Michigan Speaker’s Bureau?

Yes_________  No_________(if yes, please attach copy of resume/curriculum vitae)

Would you be interested in becoming a Asthma Network Of West Michigan mentor?  Yes______   No________

Please check the following committee(s) you would be interested in joining:

__Advocacy   __Education    __Finance

__Marketing/Development      __Membership      __Research