Walk4Hearing is May 18, 2024!

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:

    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