Name of Organization:___________________________________________________________________
Director's Name:___________________________________________Title:_________________________
Address:______________________________________________________________________________
City:_______________________________________State:___________Zip:_______________________
Phone:______________________________________Fax:______________________________________
Email:______________________________________Cell:______________________________________

Organization's website address (URL): http://___________________________________________
Note: As a benefit to MASC members, website address and link will be posted on the MASC website www.MIseniorcenters.org

Other staff to be listed:
Name:___________________________________Email:__________________________________________
Name:___________________________________Email:__________________________________________
Name:___________________________________Email:__________________________________________
Name:___________________________________Email:__________________________________________
Name:___________________________________Email:__________________________________________

Cost of Michigan Association of Senior Centers Membership Dues for 2009:
(Please check type of membership)

Organizational:	$ 75.00	(Senior Centers)
Affiliated:	$150.00	(Organizations that are associated with senior centers)

Make all checks payable to: Michigan Association of Senior Centers (MASC)