APPLICATION for MEMBERSHIP   
NATIONAL WOMEN'S CAUCUS of the GREEN PARTY of the UNITED STATES


The GPUS National Women's Caucus requires verification from your state that you are a Green Party member.  If you are not sure who to contact in your state, you can find that information through the "affiliate state parties" page at <http://www.gp.org>; or, simply let us know and we can help you get in touch with the appropriate person.

To join, please fill out the first portion of this form; then forward this message to your state Green Party chair or co-chairs, national Green Party delegates, or membership secretary, and ask them to complete the second portion and forward your application to 
natlwomens-caucus@gp-us.org .  GPUS Delegates are automatically verified, but we still need your reply with the information requested below in Part I of the form and in part II state that you are a delegate.

PART I Ð To be filled out by applicant

Name:
Address:
Street/P.O. Box:			
City:					
State:				
ZIP:
Phone #:				
Phone 2:
E-mail address: 

Please list membership in any other Green Party Caucuses:

Please list any local, state or national Green Party offices you currently hold, if any:

Please list any public elected or appointed office you hold.

Because we want the Caucus to be as diverse and inclusive as possible in membership, leadership, participation, candidates for public office, media inclusion, speakers, etc., please provide the following information to help us comply with the Caucus mission, draft by-laws and the GPUS key value of diversity and inclusion. You are not required to provide this information to be a member, but it would be very helpful in enabling us to ensure diversity and inclusion. 

Please check all that apply:
a)  	Elder
b) 	Youth			
c)  	Disabled
d) 	GLBTIQ
e) 	American Indian
f)  	Black
g) 	African American
h) 	Latino
i)  	Asian
j) 	White
k)  	Other (specify) 

PART II: Verification Ð to be completed by state Green Party chair/co-chairs (or national GPUS delegates or membership secretary) and forwarded to natlwomens-caucus@gp-us.org

ÒWe certify that the applicant named above is a member of the State Green Party listed on the application, and that the information included is, to the best of our knowledge, accurate.Ó

Name: 
Office (chair, co-chair, membership secretary, or national GPUS delegate):
State Party:
E-mail address:
Phone:
Address:

Name: 
Office (chair, co-chair, membership secretary, or national GPUS delegate):
State Party:
E-mail address:
Telephone:
Address:

Thank you for applying to the National WomenÕs Caucus. The NWC is an all volunteer organization.  Please be patient while we process your application. If you would like to check on the status, please write natlwomens-caucus@gp-us.org

















NATIONAL WOMENÕS CAUCUS of the GREEN PARTY OF THE UNITED STATES



natlwomens-caucus@gp-us.org
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National WomenÕs CaucusÑApplication
Green Party of the United States