APPLICATION FOR MEMBERSHIP

NAME: _________________________________________________________________

PREFER TO BE CALLED: ________________________________________________

TITLE: _________________________________________________________________

WORK ADDRESS: _______________________________________________________
________________________________________________________________________
________________________________________________________________________

WORK PHONE: ______________ FAX: ______________E-MAIL:________________

HOME ADDRESS: _______________________________________________________

________________________________________________________________________

HOME PHONE: ____________FAX: _____________ E-MAIL:___________________

DESCRIBE MAJOR AREAS OF RESPONSIBILITY:
________________________________________________________________________
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DO YOU HAVE ANY INTEREST IN SERVING ON ANY OF THE FOLLOWING COMMITTEES:
                    Public Policy                                       YES __ NO __
                    Membership                                         YES __ NO __
                    Education                                           YES __ NO __
                    Research                                             YES __ NO __
                    Public Relations/Communications  YES __ NO __

DO YOU HAVE ANY PRIOR EXPERIENCE THAT MIGHT BE BENEFICIAL TO ANY OF THESE COMMITTEES?       YES __ NO __

ARE YOU A CURRENT MEMBER OF THE AONE? YES __ NO __ PENDING __

 SIGNATURE: __________________________________ DATE: _________________

Enclose dues in the amount $75.00 and current resume/CV with your application. Applicants joining after July 1^st will not be billed for the following year’s dues.

VOLUNTARY CONTRIBUTIONS TO VONL ACCEPTED.
Mail completed application form to: VONL, 148 Main Street, Montpelier, VT 05602
or Email to Lucie@vahhs.org