Michigan Developmental Education Consortium

MEMBERSHIP APPLICATION

Name: _______________________________________

Position: _____________________________________

Institution: ___________________________________

Work Address: ________________________________

 _____________________________________________

Phone: (work) _________________________________

           (home) _________________________________

Fax: ___________________________________

E-mail: _________________________________

OK to allow professional contacts?              Yes      No

OK to allow vendor contacts?                       Yes      No

Current NADE member?                              Yes      No

Would  you be interested in recruiting for MDEC on your campus?

 Yes      No

Please list other professional organizations to which you belong:

 ______________________________________________

  ______________________________________________

Your primary work area(s) (please check all that apply):

_____ Administration _____ Faculty/ Counselor _____ Tutoring/ Support Services _____ Advisor

_____ Two-year Institution _____ Four-year Institution

Please check areas of interest:

                                   _____ Statewide Basic Skills Assessment

                                    _____ MDEC History/ Archives

                                    _____ NADE / Networking

                                    _____ Professional Standards

                                    _____ Public Relations

                                    _____ Newsletter

                                    _____ Conference Planning

      _____ Other:_________________