150 Benefit Street,

Providence, Rhode Island

       Membership and/or Board of Directors Application


_____________________________________________________________________________             First                                               Middle                                  Last                       

Residence Address:  ________________________________________________________________

Phone __________________________           E-mail________________________________________

Interested in joining as a member    _______        Annual Dues: $10.00                                                                    

Interested in serving as director      _______        Only members are eligible to serve as directors

If you are interested in serving as a director, please complete portions 1- 4.  If not, skip to the end.

1.     Please briefly describe your academic and professional background:




2.     Please list any prior experience as a member or director of other non-profit organizations:





3.     Please describe the contribution you feel you can make to further the Subcommittee’s mission:





4.     Please share or attach any other information you feel important:




Signature of applicant: ______________________________  Date _________________________    

                                                   Thank you very much for applying