To become a member
of the Geriatric Interest Network, please print this page and complete it.
Name ________________________________________
Title _________________________________________
Preferred Mailing Address (Street) ______________________________________________
(City, State & Zip) ______________________________
E-mail address:_________________________________
Phone: Day _______________ Evening _____________
Employer:
Name ______________________________
Address _______________________________________
_______________________________________________
I do ______ do not ______ give permission to The Geriatric Interest Network
to
release my name and mailing address to other organizations upon their request.