Contributing Member Application Form

Full Name:
University:
Year of expected graduation:
Major(s):
Primary e-mail address*:
Current Mailing Address**:
Positions held in The Triple Helix (if any):
Interest areas in The Triple Helix (check all that apply):	Editing Writing Marketing Finance Web/Graphic Design Business Development Community Outreach/Service Other, please specify:

* You will receive an e-mail from us at this e-mail address after you submit your application.
** We will not mail anything to you without your express written permission beforehand.

In order to complete your application and acceptance into this membership class, you agree and officially give your consent to voting via electronic balloting methods for some or all of the elections that you qualify to vote in. Additionally, you truthfully testify that all information provided above is accurate to the best of your knowledge. You also acknowledge and approve that you will be automatically placed onto a The Triple Helix Updates listserve (e-mails are sent out every 3-4 weeks only), and you have the option of unsubscribing yourself. You also acknowledge that you may or may not be contacted in the future by The Triple Helix based on the interests you provided above.