MEMBERSHIP APPLICATION

Colorado – Minas Gerais, Brazil Chapter

I want to join and make a difference!

Membership category: ___Individual ($30/yr) ___Couple ($35/yr) ___Student ($10/yr)

Name(s): ____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________

City: __________________ State ________________ Zip _______________

Phone: (H) ________________________ (W) ___________________________

Email: ____________________________________________________________

Partners Areas of Interest:

_____Women & Families _____ Health

_____ Youth Development/Leadership _____ Cultural Affairs

_____ Education _____ Agriculture

_____ Environment _____ People with Disabilities

_____Citizen Participation _____ Business/Economic Development

_____Leadership Development _____ Public Relations/Hospitality

Other: _________________________________________________________________

________________________________________________________________________

Please send this application and check to either of the following:

Steve Waechter (Telephone: 970.506-0179) Rhoda Rogers (Telephone: 970.352-2516)

President, Partners – Colorado Treasurer, Partners - Colorado

6806 West 3^rd Street, Unit 36/Bld 24 2335 19^th Avenue

Greeley CO 80634 Greeley CO 80631

Muito obrigato!