The Senior Agenda Coalition would like to invite you to be a member of our important coalition.

Voting Member:
Name of Organization:
Address:
Phone:
Email:
Name of person representing organization:
Alternate:
Name on letterhead:	yes / no (circle one)
-or- Affiliated Member:
Name of Organization:
Address:
Phone:
Email:
Name of person representing organization:
Alternate:
Name on letterhead:	yes / no (circle one)
-or- Individual Affiliated Activist:
Name:
Address:
Phone:
Email: