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LT Senior Services Membership Application
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Business Name *
Contact's Name *
Contact Phone *
Contact Email Address *
Business/Organization Website
Business/Organization Phone Number *
Street Address *
City *
State *
Zip Code *
Mailing Address
If different from above
Business Type
Do you want to be included in our Speakers Bureau and, if so, on what topic would you speak?
Do you want to be a speaker at one of the quarterly networking meetings and, if so, on what topic would you speak?
Would you be open to hosting quarterly meeting?  What is your availability (January, April, July, October)?
On which committees might you like to participate?
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Membership Fee *
Please provide a 50-word (maximum) description of your business for use in our membership directory. PLEASE NOTE: We may condense descriptions in excess of 50 words. *
Payment Agreement - We will issue you an invoice via QuickBooks. *
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