Roundtable Brochure Information Form

Please use this form to submit your organization's information to be used in the Roundtable Brochure. The brochure's design is for an informational guide for each organization who wants to participate, not a listing of events or programs. The brochure will include basic information and a short description on your organization, one picture from your organization, a regional map, and a fun passport section. We are also considering sponsorships for the brochure. We are estimating that the cost for each organization will be about $50.00. If you have any questions, please contact Tom Haynes at 352-1895.  Thank You!

Deadline for submitted information will be 18 April.

Please copy this form and send back as a word document to Tom Haynes electronically, along with a picture in a jpg file at 300 dpi.

Name of Society: _________________________________________________

Mailing Address: _________________________________________________

                           _________________________________________________

                           _________________________________________________

Permanent Address _____ or Temporary _____

Phone: ____________________ email: ______________________________

Web Site Address: ___________________________________

Key Contact Person: _______________________________________________

Phone: ____________________ email: _______________________________

Year Established:

Dates and Hours of Operation:

Short Description of Your Organization: (In a paragraph, if you had to tell someone about your organization and what you do and have to offer, what would you like them to know.)