**All fields are required.

Institution Information Institution Name:

Department/Division:

Name of Approving Official (e.g. Department Chair, Dean) :

Title of Approving Official:

Institution type: --Select One-- U.S. Educational U.S. Nonprofit U.S. Federal/State/Local Government Foreign

Proposed Member Representative First Name:

Last Name:

Organization:

Mailing Address: City State/Province Country Postal Code

Shipping Address: (Same as above) City State/Province Country Postal Code

Phone Number:

Fax Number:

E-mail:

Please provide a 1-2 paragraph summary statement of your organization's interests for joining UNAVCO. Be sure to include a list of the members of your organization that are willing to participate in UNAVCO meetings and to help govern the UNAVCO community. Also, include their fields of interest.

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