APPLICATION:
Name: ______________________________________________________________________
Home Address: _______________________________________________________________
City: _____________________________State: ______ Zip: ______________
School Name: _______________________________ County: ____________
School Address: ______________________________________________________________
City: _____________________________State: ______ Zip: ______________
School Phone: _______________________ Fax: ______________________
Educational Employment History:
| Place: | __________________________ |
| Position: | __________________________ |
| Years: | ___________________ |
| Place: | __________________________ |
| Position: | __________________________ |
| Years: | ___________________ |
Participation in local Library Media Organization:
________________________________________________________________________________
________________________________________________________________________________
Participation in MEMO:
________________________________________________________________________________
________________________________________________________________________________
Participation in other Conferences/Conventions/Workshops/Seminars in last three years:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Personal and/or professional benefits you will receive from attending the MEMO Conference:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________
Signature of Applicant/Date