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LANA

           

I am interested in serving on the Louisiana Aging Network Association (LANA) for three years or I would like to nominate someone to the board. 

 

NAME:                                                                                               

 

ADDRESS:                                                                                       

 

                                                                                                          

 

Telephone:                                        

 

Email Address:                                                                               

 

EMPLOYER:                                                                                    

 

ADDRESS:                                                                                       

 

 

 

Briefly describe why you are interested in serving or feel your nominee would be a good board member:

 

                                                                                                                  

 

                                                                                                                  

 

Describe your area of interest in the aging network or committees you are interested in serving:

 

                                                                                                                  

 

 

                                                                                                                  

 

 

Signature:                                                     

 

Date:                            

 

Mail ballot to:      LANA

1001North Reed Street

Ville Platte, LA  70586