Kildare PPN Membership Registration Form

Part A - Details of Organisation

1.
A. Organisation Details

URL

Name of Organisation

Address of Organisation

Town

County

Website Address

Twitter Address or Handle

Facebook Address or Page

Email Address for Organisation

Confirm you can be contacted primarily by email
Main means of communication in the future will be via social media/email - so it is important to supply Email address

B. Main Contact Person

Name1st Name: Surname:

Contact Address

Town

County

Telephone No.

Mobile No.

Email Address

2.
Brief Description of Organisation and Activities

3.
Complete as appropriate:

Chairperson name1st Name: Surname:

Secretary name1st Name: Surname:

Treasurer name1st Name: Surname:

When was Organisation set up? Month: Year:

Year of last AGM

6.
Does your organisation have any of the following?

Constitution Articles of Association Written Guidelines None of These

Number of members in organisation

If Affiliated to other Umbrella Group Please specify:

Is your group providing services Countywide? Yes No

10.
Electoral College or Pillar

What is the main focus of your Organisation? Please tick, as appropriate

Community & Voluntary ( local development, sports, social groups )

Social Inclusion (focussed on people experiencing disadvantage & inequality)

Environmental (focussed on protecting the environment & sustainable development)

11.
Municipal District (Electoral Area)

Which is most appropriate to your organisation? (See Map)

Athy

Celbridge-Leixlip

Maynooth

Kildare-Newbridge

Naas

Part B - Complete only if it applies to your Organisation

Number of staff employed in org: Number of Volunteers:

Number on C.E/Job Bridge/TUS :

Part C - Representative or Alternate to County Kildare PPN Plenary

If your organisation expects to attend any meetings of the PPN, please indicate below, main representative/alternate, who will attend.

	Representative
Name	1st Name Surname
Address
Town
County
Phone
Mobile
Email

	Alternate
	1st Name Surname

Town
County

Part D - Declaration

I understand that data supplied on this form can be used to send information about County Kildare Public Participation Network (PPN) and its activities, and other items which the PPN considers may be of interest to PPN organisations in Kildare. I understand that this application is subject to validation before registration is completed. I confirm that the information supplied on this membership registration form is correct.

Name: Position in Organisation:

Kildare Public Participation Network

For community, voluntary, social inclusion and environmental organisations

Register Now

Kildare PPN Membership Registration Form

1.
A. Organisation Details

B. Main Contact Person

2.
Brief Description of Organisation and Activities

3.
Complete as appropriate:

6.
Does your organisation have any of the following?

10.
Electoral College or Pillar

11.
Municipal District (Electoral Area)

Representative

Name

Address

Phone

Mobile

Email

Alternate

Kildare Public Participation Network

For community, voluntary, social inclusion and environmental organisations

Register Now

Kildare PPN Membership Registration Form

1. A. Organisation Details

B. Main Contact Person

2. Brief Description of Organisation and Activities

3. Complete as appropriate:

6. Does your organisation have any of the following?

10. Electoral College or Pillar

11. Municipal District (Electoral Area)

Representative

Name

Address

Phone

Mobile

Email

Alternate

1.
A. Organisation Details

2.
Brief Description of Organisation and Activities

3.
Complete as appropriate:

6.
Does your organisation have any of the following?

10.
Electoral College or Pillar

11.
Municipal District (Electoral Area)