Mail E
Extension Connection Subscription 2017 Building Strong & Vibrant New York Communities
Extension Connection Subscription 2017 Building Strong & Vibrant New York Communities
www.sullivancce.org
www.sullivancce.org
*Name:____________________________________________
*Name:____________________________________________
Company:__________________________________________
Company:__________________________________________
*City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
New Enrollee
Renewal
I would like to receive my Extension Connection Newsletter via:
E-mail
Donation $25.00
I would like to make an additional contribution to Cornell Cooperative Extension in the amount of: $_____________
*City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
CCESC has my permission to use photos of me for marketing and educational purposes. New Enrollee
E-mail Payment Information
Payment Information
E-mail saves important funds for programming.
*Address:____________________________________________
Cash Amount:
Donation $25.00
Mail
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:
Check Amount & #:
1 Year
E-mail saves important funds for programming.
FOR OFFICE USE ONLY Date Deposited:
Renewal
I would like to receive my Extension Connection Newsletter via:
1 Year
Mail
Total Amount Enclosed:
*Required
*Required
CCESC has my permission to use photos of me for marketing and educational purposes.
Contact Information
Contact Information
*Address:____________________________________________
Cash Amount:
Check Amount & #:
Enrollment 2017
Enrollment 2017 I am a full time resident of Sullivan County I am a seasonal resident
I am a full time resident of Sullivan County I am a seasonal resident
from ____________________ to ______________________
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)? Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
What programs would you like to receive opportunities for (check all that apply)? Interests
Interests
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
Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
Demographic Data (OPTIONAL)
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.
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.
Please select all that apply to you. Ethnicity & Race
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Demographics
Demographics
Ethnicity & Race
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Gender Identity
Gender Identity
Female Male Other
Female Male Other
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
Cornell Cooperative Extension in Sullivan County is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.
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
Cornell Cooperative Extension in Sullivan County is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.
Extension Connection Subscription 2017 Building Strong & Vibrant New York Communities
www.sullivancce.org
www.sullivancce.org
*Name:____________________________________________
*Name:____________________________________________
Company:__________________________________________
Company:__________________________________________
*City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
New Enrollee
Renewal
I would like to receive my Extension Connection Newsletter via:
Donation $25.00
I would like to make an additional contribution to Cornell Cooperative Extension in the amount of: $_____________
*City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
CCESC has my permission to use photos of me for marketing and educational purposes. New Enrollee
E-mail Payment Information
Payment Information
E-mail saves important funds for programming.
*Address:____________________________________________
Cash Amount:
Donation $25.00
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:
Check Amount & #:
1 Year
E-mail saves important funds for programming.
FOR OFFICE USE ONLY Date Deposited:
Renewal
I would like to receive my Extension Connection Newsletter via:
1 Year
Total Amount Enclosed:
*Required
*Required
CCESC has my permission to use photos of me for marketing and educational purposes.
Contact Information
Contact Information
*Address:____________________________________________
Cash Amount:
Check Amount & #:
Enrollment 2017
Enrollment 2017 I am a full time resident of Sullivan County I am a seasonal resident
I am a full time resident of Sullivan County I am a seasonal resident
from ____________________ to ______________________
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)? Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
What programs would you like to receive opportunities for (check all that apply)? Interests
Interests
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
Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
Demographic Data (OPTIONAL)
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.
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.
Please select all that apply to you. Ethnicity & Race
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Demographics
Demographics
Ethnicity & Race
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Gender Identity
Gender Identity
Female Male Other
Female Male Other
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
Cornell Cooperative Extension in Sullivan County is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.
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
Cornell Cooperative Extension in Sullivan County is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.
