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<title>Jennings Randolph Recognition Project Enrollment Form</title>
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<p align="center"><b><font face="Arial" size="3">
<img border="0" src="images/agrilogo-small.gif" width="100" height="111"><br>
</font><font face="Arial" size="4">JENNINGS RANDOLPH RECOGNITION PROJECT</font></b></p>
<p align="center"><font face="Arial" size="3">Enrollment Form</font></p>
<p align="center"><font face="Arial" size="2">(There is no financial obligation associated with your
participation.)</font></p>
<p align="center"><font face="Arial" size="3">
<img border="0" src="images/checkbox-small.gif" width="18" height="17">
Please list me/my organization as a supporter of the <br>
Jennings Randolph
Recognition Project to memorialize <br>
his contributions and to strengthen
the values that <br>
Randolph espoused in his public service to <br>
West
Virginia, the nation, and the world. </font></p>
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<td width="104"><font face="Arial" size="3"><b><i>Organization</i></b>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><i><b>Your Name</b></i>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><i><b>Title</b></i>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><b><i>Address</i></b>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
</tr>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><b><i>City/State/ZIP</i></b>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306">
</td>
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<td width="104"><font face="Arial" size="3"><i><b>Telephone</b></i>:</font></td>
<td width="306">
<p align="left"><font face="Arial" size="3">____________________________________________________________</font></td>
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<tr>
<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><i><b>Fax</b></i>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
</tr>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><i><b>E-mail</b></i>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104"><img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306"></td>
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<td width="104"><font face="Arial" size="3"><i><b>Signature</b></i>:</font></td>
<td width="306"><font face="Arial" size="3">____________________________________________________________</font></td>
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</table>
</center>
</div>
<p align="center"><font face="Arial" size="3">You will receive
invitations to memorial events,<br>
planning meetings and related
activities.</font></p>
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<center>
<p align="center"><b><font face="Arial">The Agribusiness Council - JRRP</font><font face="Arial" size="3"><br>
P.O. Box 5565<br>
Washington DC 20016</font></b></p>
<p align="center"><b><font face="Arial" size="2">"Building bridges
through associations with peoples of the world."</font></b>
<p align="center"><b><font face="Arial" size="2"><a href="randolph.htm">Randolph
Recognition Project</a></font></b>
<p align="center"><b><font face="Arial" size="2"><a href="contribution_form_jr.htm">Contribution
Form</a></font></b>
<p align="center"><b><font face="Arial" size="2"><a href="http://www.Agribusinesscouncil.org/default.htm">Home</a></font></b></td>
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