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1. Name: ______________________________________________________________ 2. Location: ___________________________________________________________ 3. Contact Person: _______________________________________________________ 4. Address: ____________________________________________________________ _______________________________________________________________________ 5. Telephone: _______________________ E-Mail: _____________________________ 6. Websites: ____________________________________ Number of members: ______ 7. Names and Titles of Officers (if any) a. ______________________________________________ b. ______________________________________________ c. ______________________________________________ d. ______________________________________________ 8. Objectives: a. ____________________________________________________________________ _______________________________________________________________________ b. ____________________________________________________________________ _______________________________________________________________________ c. ____________________________________________________________________ _______________________________________________________________________ 9. Principles: a. ____________________________________________________________________ b. ____________________________________________________________________ c. ____________________________________________________________________ 10. Grass Roots Support (elections, petitions, meetings) ____________________________ ________________________________________________________________________ ________________________________________________________________________ 11. Media Attention: ______________________________________________________ _______________________________________________________________________ 12. Political Strategies: a. _____________________________________________________________________ b. _____________________________________________________________________ c. _____________________________________________________________________ 13. Major Successes: _____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 14. Biggest Challenges: ____________________________________________________ ________________________________________________________________________ 15. Date formed_________ Brief History: Attach a copy, if available. Reply to: Kirkpatrick Sale 127 East Mountain Road Cold Spring, NY 10516 845-265-3158 Email to: Director@MiddleburyInstitute.net |