Long Island Women's Agenda

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Individual Membership Application Form

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1. Annual Dues

LIWA's membership year is from July 1st to June 30th.

Individual
$50.00
Donation
$
Total
$

2. Background Information

* Name:


Title:


Company/Organization:


* Address:



* City:


* State:


* Zip:


* Telephone:


Fax:


* Email Address:


* Does this information pertain to your:
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3. Please list any women's organization(s) that you belong to.

If none, enter "none."

4. What LIWA issues are of particular importance to you?


5. Committee Selection

Which committee(s) would you like to join?
Business & Economic Development
Communications
Development
Emerging Leaders
Health
Leadership Council
Legislative Affairs
Membership
Work & Family

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