Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you able to commit to a three-year Board term, attendance at monthly Board meetings (3rd Wednesday of the month from 7pm-9pm at the Midtown Office) and approximately 4 hours a month of volunteer service on the Board? *

Yes

No