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The "us" Project, Inc.

Membership Information Request

For information on FREE Membership as a Volunteer or as a Client Group, in "us" please complete as much of the below information as you can. It will be E-Mailed directly tto "us", and will be kept completely confidential.

Full Name      
e-mail address 
Title          
Organization   
Dept/Box       
Street         
City/State/Zip 
Country        
Day Phone      
Eve Phone      
FAX Phone

Does Your Organization have a WEB Site ?

URL            
Description

The following info is optional

Male/Femanle    Date of Birth

What are your primary Interests ?

If you are Currently involved, What Groups do you work with ?

Comments/Suggestions/Questions  ?