Coordinator's Information Form

Please provide ALL information for WFS staff use. If there is any information you do not want published, please list it in the DO NOT PUB field.

Name:
 Affiliation: (company or occupation)
Address: (work)
 Address: (home)
City/State
 Country                       
Zip/Postal Code
Phone: (work)
 Phone: (home)
Where do you prefer being contacted regarding chapter activities? work home
Fax:
E-mail:

DO NOT PUB:

Length of time a World Future Society member: Society meetings attended:
WFS publications received:
 Types of activities you plan:
Major areas of interest:
Business
Health
Careers Human values
Communications International Affairs
Design Leisure
Demography Lifestyles
Economics Population
Education Research Methods
Energy Resources
Environment Technology
Government Transportation

Other

Meetings should include:
Meals
Noteworthy speakers		 Discussions
Media
Other

The most important function of our local chapter should be to:

Give a brief biographical sketch of yourself: