Membership Form
4300 16th
St. NW
Washington DC 20011
(202) 545 – 0139 (office / fax)
Name: ____________________________________________________________
Address: __________________________________________________________
City: ___________________________ State: ________ Zip code:____________
Country: ________________________
Telephone: [H] (________) ________________________________
[W] (________) ________________________________
[FAX] (________) ______________________________
E-Mail:___________________________________________________
AMOUNT ENCLOSED
[ ] Membership Friends of Liberia:
Membership donation (minimum $40) ___________
[ ] Membership in the National Peace
Corps Association:
$25/year or $32.50 family membership (OPTIONAL) ___________
[ ] Additional Contribution: Advocacy,
LEAP,
GCA, Buy-A-Book, FOL activities. ____________
TOTAL ENCLOSED
Make checks payable to “Friends of Liberia”
In order to improve our data base, please answer the following questions.
What years did you live/work
in Liberia? ________________________________
____________________________________________________________
In what capacity did you live/work in Liberia?
Liberian citizen: _____ Peace Corps Volunteer/Staff: _____ Missionary: _____
U.S. Government: (please
specify) ____________
Business: _____ What company? _______________________________________
Other capacity: (please specify) ________________________________________
Where did you live in Liberia? _________________________________________
__________________________________________________________________
If you were a PC Volunteer, do you remember your group number? ____________