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Public Service & Not-for-Profit Organizations & Activities
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| Name: | |||
| Street Address: | |||
| City: | |||
| State: | Zip: | ||
| Phone: | |||
| Email: | |||
| Nature of Service or Activity: | |||
| Chief Officer or Contact: | |||
| Contact Phone: | |||
| When & Where Group Meets: | (if applicable) | ||
| Time of Year New Leadership Chosen: | (if applicable) | ||
| Signature: | ________________________________ | ||
| Title: | |||
| Phone Number: | |||
| Date: | |||