PROTECT LIFE PARTNER APPLICATION

Signer's Info

Name*

Address*

Email*

Phone Number*

Your Officer Position (Signer Must be An Officer)*

Secondary Contact's Info

Secondary Contact Name (another officer we can reach)*

Secondary Contact's Email*

Secondary Contact's Phone Number*

Secondary Contact's Officer Position*

Multiple Choice*

Current Name of the Group You Represent (if applicable)

NEW Protect Life Name You Desire to Use if Approved (if applicable)

Please Check the Items You'd Like Included in Your Promotional Packet:*

Please provide us with information on what materials and support you need in your potential transition:*

What colors would you like on your banner? Please be as specific as possible, including HTML color codes if you have them:

What would you like on your banner? Any specific text? Your mission? Facebook/Twitter/Instagram? Please be specific:

Please provide us with a name & mailing address to send the promotional package to:*

For complete terms of this agreement, see Section XI of Protect Life Michigan's Bylaws.

By signing below, I confirm that I have read, understand, and agree to comply with Protect Life Michigan's Bylaws.

Written Signature (type name):*

This page is secured with 256 bit encryption