First & Last Name:

Mailing Address:     Apt./Suite:

City:     State:     Zip:

E-mail:

Please provide a telephone number where we can contact you.

Day Phone:     Other Phone:

Please check the items you're interested in doing. Check more than one box if you'd like.

I will do tabling at events I will do event organizing I can do fundraising I will write letters (media and others) I will work on issues (specify below) I volunteer to (specify below)

I will do leafletting I will do door-to-door outreach I can do office work I can do literature/graphic design I will locate endorsers for the effort I can maintain the Web site

Comments or Questions:

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