HRG PEER CIRCLES

MEMBERSHIP FORM

Date: ..................................................

Name of Organization (if an organization): ..............................................................

Name of Responding Person: ................................................................................

Position in the Organization: .................................................................................

Address: ..............................................................................................................

City......................... State ............. Postal Code ............ Country .........................

Fax ........................... Phone ............................ Mobile: ........................................

E-mail ....................................... Web site (if any): .................................................

  Do you like to actively join the activities of Home Rule Globally?     Yes         No

 Do you like to be nominated as a Focal Point for HRG PEER CIRCLES?   Yes      No

 Would you like to send a representative from your organization to work with the International Committee? 

     Yes      No

    If YES, please tell us the name of the representative: ...............................................

 Would you like to send delegates to the upcoming GLOBAL ASSEMBLY and to other conferences?

     Yes            No

    If YES, please tell us the names of your delegates:
           
1. .........................................................................  

2. ..........................................................................

 I am an INDIVIDUAL. Please register me as a member of the HRG PEER CIRCLES.

Signature of the President/CEO of your organization: .................................................

Signature of the Secretary General/Director of your organization: ..................................

Please return to:

HRG PEER CIRCLES
E-mail: peercircles@homeruleglobally.org