MAG-Net Membership Pledge

Submitted by LisaJ on Mon, 2011-02-28 19:14

Today's Date: *

Organization Name: *

Address: *

Additional Address (if necessary):

City: *

State: *

Zip Code: *

Executive Director's Name: *

Executive Director's Daytime Phone Number: *

Executive Director's Email Address: *

Name of Organizational Contact Person for MAG-Net: *

Contact Person's Daytime Phone Number: *

Contact Person's Email Address: *

Contact Person's Cell Phone Number: *

Provide a brief description of your organization and the constituency you work with: *

What strengths and experiences can you bring to the network?: *

What would you like to get out of being a member?: *