ACTIVE MEMBER

*Name:

*Address or PO Box:

*Telephone number

*Email address *Would you like the IPN email newsletter? State yes or no.

*Would you like the IPNtel briefings? State yes or no.

*Do you plan to become an active member? State yes or no.

*Have you ever been convicted of a felony crime? If so, you are not eligible to be an IPN Active Member.

*Do you have any special skills you would like to share with IPN? If so, please describe in a few sentences.

*Would you be willing to volunteer your services or share your skills with other members? State yes or no.

*Would you be willing to volunteer to assist emergency service personnel during disasters and emergencies? State yes or no.

*Do you plan to test for higher levels in IPN? State yes or no.