2018 Extension Connection Subscription
2018 Extension Connection Subscription Building Strong & Vibrant New York Communities
www.sullivancce.org
*Name:____________________________________________ Company:__________________________________________
Contact Information
*Address:____________________________________________ ____________________________________________________ *City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
*Required
CCESC has my permission to use photos of me for marketing and educational purposes. New Enrollee
Renewal
I would like to receive my Extension Connection Magazine via:
E-mail
1 Year Donation $25.00
Mail
Payment Information
E-mail saves important funds for programming.
I would like to make an additional contribution to Cornell Cooperative Extension in the amount of: $_____________
Total Amount Enclosed:
$_____________
FOR OFFICE USE ONLY Date Deposited:
Cash Amount:
Check Amount & #:
2018 I am a full time resident of Sullivan County I am a seasonal resident from ____________________ to ______________________
I am a weekend resident I am retired I am a student I am a(n) _________________________________ farmer I am a veteran I don’t live in Sullivan County but I work or visit often
What programs would you like to receive opportunities for (check all that apply)?
Interests
Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
Demographic Data (OPTIONAL) Demographic data is an important tool that informs our organization about our members so that we can better serve the people of Sullivan County. This information is maintained in a secure database and only used for reporting and program planning purposes. This is optional.
Please select all that apply to you. Ethnicity & Race
Demographics
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Gender Identity Female Male Gender Not Listed Pay by cash, check, or credit (online/office). Please make checks payable to CCESC Mail to: 64 Ferndale-Loomis Road Liberty, NY 12754 CALL 845-292-6180 E-MAIL [email protected]
FAX 845-292-4946 VISIT www.sullivancce.org
Diversity and Inclusion are a part of Cornell University’s heritage. We are a recognized employer and educator valuing AA/EEO, Protected Veterans, and Individuals with Disabilities.
www.sullivancce.org
*Name:____________________________________________ Company:__________________________________________
Contact Information
*Address:____________________________________________ ____________________________________________________ *City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
*Required
CCESC has my permission to use photos of me for marketing and educational purposes. New Enrollee
Renewal
I would like to receive my Extension Connection Magazine via:
1 Year Donation $25.00
Payment Information
E-mail saves important funds for programming.
I would like to make an additional contribution to Cornell Cooperative Extension in the amount of: $_____________
Total Amount Enclosed:
$_____________
FOR OFFICE USE ONLY Date Deposited:
Cash Amount:
Check Amount & #:
2018 I am a full time resident of Sullivan County I am a seasonal resident from ____________________ to ______________________
I am a weekend resident I am retired I am a student I am a(n) _________________________________ farmer I am a veteran I don’t live in Sullivan County but I work or visit often
What programs would you like to receive opportunities for (check all that apply)?
Interests
Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
Demographic Data (OPTIONAL) Demographic data is an important tool that informs our organization about our members so that we can better serve the people of Sullivan County. This information is maintained in a secure database and only used for reporting and program planning purposes. This is optional.
Please select all that apply to you. Ethnicity & Race
Demographics
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Gender Identity Female Male Gender Not Listed Pay by cash, check, or credit (online/office). Please make checks payable to CCESC Mail to: 64 Ferndale-Loomis Road Liberty, NY 12754 CALL 845-292-6180 E-MAIL [email protected]
FAX 845-292-4946 VISIT www.sullivancce.org
Diversity and Inclusion are a part of Cornell University’s heritage. We are a recognized employer and educator valuing AA/EEO, Protected Veterans, and Individuals with Disabilities.
