2008 Membership Application
(January 1 through December 31, 2008)

Name (First, M.I., Last): Title:

Organization:

Address:

City: State: Zip:

Email:

Phone: Fax:

Type of organization (i.e. Home Health Care):

Please choose a level of membership:

Platinum $750

Gold $500

Silver $350

Bronze $250

Individual $30

Student/Retiree $25

If you are interested in joining a committee, please choose from the following list:

Communications

Education
Membership

Nominating
Special Events

You may also print this application and send it to the Network office.
Please make checks payable to:
Network in Aging of WNY, Inc.
University at Buffalo, 515 Kimball Tower
3435 Main Street, Buffalo, New York 14214-3079

University at Buffalo, 515 Kimball Tower, 3435 Main Street, Buffalo, New York 14214-3079

Phone (716) 829-3712        Fax (716) 829-3217        E-mail  jll7@acsu.buffalo.edu