IUPUI : Senior Academy : Membership : Application

Full Name:	Email Address:
Phone #:	Fax #:
Mailing Address:	City: State: Zip:

Do you expect to spend a significant part of your time in the Indianapolis area, enabling you to make a time commitment to the Academy? (We recognize the difficulty of those not in this geographical vicinity to make this time commitment. Such individuals my contribute in other ways.)		Yes No Other (Explain)

Retirement Information	Date:
Title:	School/Dept:

Areas of interest in which you would especially like to be involved:

Membership Dues: Please enclose your check with this application. $10 Annual Dues $100 Lifetime Member	Return to: IUPUI Senior Academy 355 N. Lansing Street, AO 126 Indianapolis, IN 46202

Signature:____________________________________	Date:

Membership Application