NICA Advocate Survey

1.Please fill out the contact information below.

First Name:

Last Name:

Company:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

2.Can we list your name, email and interest level on the NICA Neighborhood Map? (The map, linked off the NICA homepage, can be viewed here http://bit.ly/eV5Ym7)(Required.)

Yes

No

Yes, but no email address please

3.Please select your interest level below:

I would like to build/lead a NICA club/team

I would like to build/lead a NICA League (could include building a club/team)

I would like to play a supporting role for the above (but not be the leader)

Other (please specify)

NICA Advocate Survey

13.Contact Information