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Note: Print the form below and mail it to the Address given under:

FORUM ON IRAQ

I/We belonging to the organization mentioned below would like to become a member of the Forum on Iraq.

Organization Name:                 _____________________________________________

Main Office Address:               _____________________________________________

City:_________________________________________

State:_______________Zip:______________________

Phone: (____)___________ Fax: (____)____________ Web:   _____________________

Check All Appropriate Boxes:

Contact Person’s Name:

First Name:______________ Last Name: _______________ Title/Position: ______________

Address:           _____________________________
 

City:                _____________________________

                       State:__________ Zip:___________

Phone: (_____)_______________ Fax: (_____)_______________

Email:   _________________________ Cell/Sat Phone: ___________________________

Explain in less than 100 words, goals and scope of your organization and what you

expect from the FORUM:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

What do you like to see THE FORUM ON IRAQ to do: __________________________________________________________________________

__________________________________________________________________________

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Authorized Signature:    ____________________________    Date:   ________________

Print Name:                  ____________________________