You can print out the form shown by clicking on print at the bottom of the page
and mail it to The PLATO Society of UCLA,
1083 Gayley Avenue, 2nd floor, Los Angeles, CA 90024-1333
Membership Application
Name__________________________________________________ Date_____________________
Address___________________________________________________________________________
City _______________________________________ State ___________________ Zip _____________
Phone No. ( )___________________ Fax No. ( )____________________
E-Mail Address ___________________________
Employment Status: [ ] Working Full-Time [ ] Working Part-Time [ ] Retired
Career Information: Please describe your career history, with names of organizations, lengths of involvement, etc. Attach additional information on a separate page if necessary. __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Educational Background: Please indicate any college or university attendance, with degrees obtained.
Note: A college degree is not a requirement for membership.
___________________________________________________________________________________
___________________________________________________________________________________
Please list any special interests, hobbies, fields of study, leadership experience, and books recently read:
___________________________________________________________________________________
___________________________________________________________________________________
Please list any volunteer work or community activities:
___________________________________________________________________________________
How did you hear about PLATO?__________________________________________________________
Personal Statement: Should you desire, you may prepare and attach a brief statement on your reasons for wanting to join The PLATO Society, how you might contribute to the society, and what it might offer you. Indicate if you have previously been a member of PLATO.
I understand that a member of The PLATO Society will contact me to schedule a personal meeting. I also understand that the first year is provisional and the annual membership fee of $485 is payable upon registration.
Signature__________________________________________Date______________________
The PLATO Society of UCLA 1083 Gayley Avenue -- 2nd Floor
Los Angeles
CA 90024 - 1333
Tel 310 / 794-0231
Fax 310 / 794-0672
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