PrintRegForm

Print an EPPN Registration Form for a Friend!

Name (Prefix, First, Last):
__________________________________________________________________________

Address Line1:
__________________________________________________________________________

Address Line 2:
__________________________________________________________________________

City, State Zip:
__________________________________________________________________________

Home Phone: ________________________________

Office Phone: ______________________________________

Fax: _______________________________________

Email:
__________________________________________________________________________

Parish:
__________________________________________________________________________

Diocese:
__________________________________________________________________________

Do you have a friendship with a member of the House or Senate? If so who?

__________________________________________________________________________

Please Indicate if you have a particular interest in event or activities related to the issues below:

_____     Children's Advocacy
_____     Criminal Justice
_____     Economic and Social Justice
_____     Environmental Stewardship
_____     Health and Human Needs
_____     HIV/AIDS
_____     Justice for Women and Families
_____     Racism/Discriminaton
_____     Refugee/Immigration Policy

Please return this form to:
The EPPN
110 Maryland Ave., NE
Suite 309
Washington, DC 20002