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2. 
3. Membership Application - Leadership Link #517
   Please fill out the following fields and submit form when completed. Thank you!
4. 
6. Name*
7. Title*
9. Department*
10. Department Address
12. Work Phone Number*
13. Fax Number
14. Email Address*
16. Home Address
17. City, State
18. Zip Code
20. Referred By:
22. Dues are $72.00 per year can be paid through a $6.00 per month payroll deduction.
24. Preferred Method for Membership Dues (Select One)*
    -- Select One --I would prefer my dues ($6.00/month) be paid via payroll deduction.I am part of the Emerging Leaders program and will have my deduction ($6.00/month) begin 6 months after joining.
26. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature
29. Date of Application*
    Date of Application

31. If you have any questions, feel free to contact Shanda Hubka at 402-441-1720 or SHubka@lincoln.ne.gov.

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field