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STATE DELEGATE APPLICATION

It is really easy to sign up to be a State Delegate of the National Participant Network. We just need to have some basic information about you. Use this on-line form or download a PDF version to print for mailing or other distribution.

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Please check all that apply to you. If a checkbox is accompanied by a text entry the text entry will require input.

 
 
 
 
 
 
 


Please list any of your memberships with groups that provide advocacy and/or information sharing between people with disabilities. If you hold any position within a group other than general member, please indicate your level of involvement.

 
 
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 Yes   No
 
 
 
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Thank You! If you have any questions, please do not hesitate to contact our NPN Coordinator Althea McLuckie using the information below.

National Participant Network
1251 Sunset Road
Taos, NM 87571
NPN logo
Email:  NPN Membership Administration
Phone:  575.776.1755