Peoples Congress Membership Form

Please print this form and fill it out by hand.  Print is preferred.

Membership Type
___Adult
___Youth
Please indicate if you are also a member of one of our allied organizations.
___Alliance for Global Justice
___NOWDC
___Public Banking Institute
___Occupy
___Peaceful Uprising
___Soldiers For Peace International
___UNAC
___None of these
Other________________________________________________________________________________

Do you want a seat in the National General Assembly sponsored by the People’s Congress in Washington DC?
___YES
___NO
If you plan to attend the People’s Congress this July 25 – 29, 2012, please tell us how you would like to be involved.
___I want to work on a committee
___I want to be a delegate in the People’s Congress Inaugural National Assembly
___I want to be there to show my solidarity, but will probably not participate in the committees or vote.Name
Members e-mail________________________________
Confirm your e-mail_____________________________
Country of Residence____________________________
Zip-code______________________________________
Street Address__________________________________
City or Town___________________________________
State________
Date of Birth__________________