Individual Membership Form

Name*

First Last

Institution of individual*

(e.g. State University, Bigtown College-Secondcampus, etc.)

Preferred email of individual*

Campus phone of individual*

Is there a gen ed committee/program/office/department/school on campus?*

Yes
No

What is the official name of the above gen ed entity?

Campus address for gen ed entity?

(e.g. Main Hall Rm 100, MC1000, etc.)

If available, please provide a web address to the above entity.

(e.g. www.stateuni.edu/gened)

Position associated with your work in general education

(e.g. Director/Chair of General Education, Chair/member of a gen ed committee, gen ed faculty, etc.)

Individual Membership*

Individual Membership

Acknowledgment*

PayPal is the AGLS credit card processing portal. You DO NOT need to have a PayPal account. You can pay with a credit card. Simply select the option to pay as a guest/with a credit/debit card.

I Understand

Total

$0.00

Name

This field is for validation purposes and should be left unchanged.