BOT Application Form

Your Name (required)

Your Email (required)

Street Address

City

Zip

Daytime Phone

Evening Phone

Indicate V, TTY, VCO or relay numbers

HLAA Affiliation: Number of Years HLAA National member - Must be current

HLAA Chapter Affiliation: Number of Years HLAA chapter member

Office(s) held:

Person with Hearing LossParent of Child with Hearing LossFamily member of Person with Hearing LossHearing Health Care Professional

Please Provide a short biography:

If you are elected to the HLAA-MI Board of Trustees, what talents do you bring with you. Examples might be; proficiency with Microsoft Office products, graphics design, grant writing, marketing, advertising, teaching,Hearing Assistive Technology(HAT), prior board of director experience at a non-profit, etc. Please list all.

Signature

Form Updated Sept 2016