MEMBERSHIP APPLICATION

Thank you for expressing an interest in BASA.  Meetings are held the 3^rd. Wednesday of each month, subject to exceptions.  To join BASA, fill out the membership information below.  Make certain all items are completed.  Mail your membership form and a check for $35.00, payable to:  Disability Network/Northern Michigan – BASA to:

Disability Network/ Northern Michigan – BASA

333 E. State St .

Please Print

Organization Name:____________________________________________________________

Representative Name:__________________________________________________________

Representative Title:____________________________________________________________

Mailing Address:_______________________________________________________________

City:_________________________________________________Zip:_____________________

Telephone:_______________________________FAX:_________________________________

Email Address:________________________________________________________________

Website:______________________________________________________________________

What services / products to you provide to the senior population?_____________________

_____________________________________________________________________________

Updated membership lists will be provided to BASA members on a monthly basis.  You may email member information changes to:  davep@myseniormortgage.com.  Only paid members will be included in the listing.  Incomplete membership applications or applications received without a check will not be processed.