Use this form may be used to
apply for
This form may be downloaded
and sent as a hard copy to:
John M. Wilson,
or e-mailed to: wilsonjml@msn.com
Conservancy name: __________________________________________________________________
Conservancy address: ________________________________________________________________
Conservancy e-mail: __________________________________________________________________
Conservancy web site (URL): ____________________________________________________________
Conservancy phone: __________________________ fax: ___________________________________
Contact name:
______________________________________
Office or position of contact within conservancy: _______________________________________________
Contact e-mail: ________________________________________________________________________
The major officers of the conservancy are (name and title): ________________________________________
_____________________________________________________________________________________
Purpose of the conservancy: ______________________________________________________________
______________________________________________________________________________________
Other information about the conservancy such as conservancy activities relevant to this application: ______________________
_______________________________________________________________________________________
Statement
of intent to become an