Government agencies that impact breastfeeding mothers and children may be invited to governmental membership in USBC. Governmental members are non-voting members of USBC.

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* 1. Agency Name

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* 2. Agency Contact Information

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* 3. Contact Person (with questions about this application)

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* 4. How has this agency been involved in protecting, promoting and supporting breastfeeding?

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* 5. Member organizations are expected to send at least one representative to attend the general session portions of every membership meeting, and to participate in USBC activities according to their engagement levels on specific topic areas. Additional representatives are encouraged to attend as often as possible. Does this agency commit to sending at least one representative to USBC membership meetings?

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* 6. Each governmental member shall name at least one (1) and no more than four (4) individual representatives to USBC.

The recent policy change allowing up to four representatives expands member organizations’ capacity to connect with collaborative work on multiple specific topic areas. You may wish to ensure that you have a representative aligned to participate in each topic area identified as Core and/or Involved Engagement Level.

Please designate this agency’s representative(s) to the USBC:

Representative 1 (This person is also your Poll Contact: the individual you wish to receive requests for survey response, etc.)

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* 7. Representative 2

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* 8. Representative 3

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* 9. Representative 4

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* 10. Member organizations are expected to report on organizational activities related to breastfeeding via the Group Profile in the USBC website. Does this agency commit to reviewing/updating its Group Profile in the USBC website at least once a year?

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* 11. Please identify the individual that will be responsible for reporting on the agency's activities.

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* 12. Signature of Applicant Representative Authorized to Apply for Membership (type full name)

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* 13. Date:

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