1.Name

2.Email 

3.Phone Number

4.Do you live, work or both in Bentonville?

5.Are you joining as an individual or representing a business/ organization? If NOT joining as an individual, please name the business/organization. 

6.Home address if joining as an individual or business/organization address if representing business/organization in Bentonville. (Street, city and Zip code)

7.What outcomes would you like to see from this Coalition?