FLORIDA ATLANTIC
UNIVERSITY

LIFELONG LEARNING SOCIETY
777 Glades Road/P.O. Box 3091
Boca Raton, FL 33431-0991
www.fau.edu/lls

2007 - 2008
NEW MEMBER APPLICATION
Boca Raton Campus
561-297-3171 - FAX 561-297-3481

Please print below:
Name: __________________________________________________

Address: ________________________________________________

________________________________________________________

Out-of-State Phone No.:____________________________________

Local Phone No.:_________________________________________

Only give spouse information, if he/she is becoming a member.

Name: __________________________________________________

Address: ________________________________________________
Out-of-State Phone No.:____________________________________

Local Phone No.:_________________________________________

Payment Options: Membership dues $30 per student.
Check: make check payable to FAU/LLS; if different names, put on separate checks.
Credit Card: ____Amex ____MC ____ Discovery ____Visa

Credit Card No.: ______________________________________

Expiration Date:(mm/yy) ____________ Security No._________ 3 digit number on back of card, except for amex, 4 digits
on front of card.

Print name as it appears on your credit card:              
_______________________________________________________

 I agree to the terms set forth by LLS as stated herein

Signature ___________________________________________


Out-of-State Information:

Date you return to Florida:_________________________________
Date you leave Florida:____________________________________