Please print this form and mail to:

Fifty/Fifty Leadership
P.O. Box 11202
Glendale, CA 91226
or
Fax to: (818) 243-2601

Name: _______________________________________________________________

Address: _____________________________________________________________

City/State/Zip __________________________________________________________

Phone: Day ( )_______________________ Eve ( ) _____________________________

Email: _______________________@_______________________________________

Please list your interest (list as many as you wish):  

Board Membership
Advisory Board
Leadership Circles
Administrative / Clerical
Special Events
Annual Gala
Other (Please tell us) _____________

When is the best time to reach you? __________________________________________

Fifty/Fifty Leadership was incorporated in Las Vegas, Nevada in 1996. The phone number is (818) 243-2322. We have a 501(c)3 classification from the Internal Revenue Service.

© 2009. This is a publication of Fifty/Fifty Leadership. All rights reserved.
www.5050Leadership.org