Michigan Tutorial Association

Membership Application/Information Form

Name: _________________________________________________________________________
Position/Title: ____________________________________________________________________
If a student, expected graduation date: _________________________________________________
Name of Tutoring Program/Department: __________________________________________________

Institution: ______________________________________________________________________
Institution Address: _______________________________________________________________
Phone Number: ________________________________ Extension:__________________________
E-mail Address: ________________________________ Fax number:________________________
Interests/Concerns in tutoring: ________________________________________________________
_______________________________________________________________________________

Would you be interested in serving on a committee? YES NO

I have specific interest(s) in:

____Elective office. Specify _____________________________________________________
____Membership Committee
____Editorial and Publications
____Professional Development
____Conference Committee
____Conference Host
____Other. Specify ____________________________________________________________

Membership fees: Make check payable to Michigan Tutorial Association

____Professional: $20.00 ____Tutor: $5.00

Membership is ____ New ____ Renewal

Mail form with your remittance to:

Joyce Van Baak, MTA Membership Chair

Grand Valley State University

200 Student Services Building

Allendale, MI 49401

(616) 331-2490