Organization Name*

Organization mailing address *

Phone number*

Fax number

Website

Name of applicant*

Email address of applicant *

How many people are in your organization

Name and email address of representative 1

Name and email address of representative 2

Name and email address of representatives 3-5 (depending on the size of the organization)

Please use the space to the right to explain your organizations interest in joining the Diversity Consortium of Tompkins County, Inc., and the anticipated impact it will have on your organization.

Any questions?