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<META NAME="Description" CONTENT="James Wormley Recognition Project">
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<title>James Wormley Recognition Project Enrollment Form</title>
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<p align="center"><font face="Arial" size="4"><b>JAMES WORMLEY <br>
RECOGNITION PROJECT</b></font></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">
<i><b>Please list me/my organization as a supporter of <br>
the James Wormley Recognition Project (JWRP)<br>
to memorialize his contributions to public service,<br>
education, and entrepreneurship, his high ideals <br>
and devotion to humanity and civility.</b></i></font></p>
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<td width="104" height="20"><font face="Arial" size="3"><b><i>Organization</i></b>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><b><i>Your Name</i></b>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104" height="21">
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<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><b><i>Title</i></b>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><i><b>Address</b></i>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104" height="21">
<img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><b><i>City/State/ZIP</i></b>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104" height="21">
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<td width="306" height="21"></td>
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<td width="306" height="21"><font face="Arial" size="3">____________________________________________________________</font></td>
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<img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306" height="21">
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<td width="104" height="20"><font face="Arial" size="3"><b><i>Telephone</i></b>:</font></td>
<td width="306" height="20">
<p align="left"><font face="Arial" size="3">____________________________________________________________</font></td>
</tr>
<tr>
<td width="104" height="21">
<img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><i><b>Fax</b></i>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<td width="104" height="21">
<img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><b><i>E-mail</i></b>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
</tr>
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<td width="104" height="21">
<img border="0" src="images/space.gif" width="15" height="14"></td>
<td width="306" height="21"></td>
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<td width="104" height="20"><font face="Arial" size="3"><b><i>Signature</i></b>:</font></td>
<td width="306" height="20"><font face="Arial" size="3">____________________________________________________________</font></td>
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<p align="center"><font face="Arial" size="3">You will receive
invitations to memorial events,<br>
planning meetings and related
activities.</font></p>
<center>
<p align="center"><b><font face="Arial" size="3">The Agribusiness Council
- JWRP<br>
P.O. Box 5565<br>
Washington DC 20016</font></b></p>
<p align="center"><font face="Arial" size="3">Thank you!</font></p>
<p align="center"><b><font face="Arial" size="2">"</font><i><font FACE="Arial" SIZE="2">Building
Bridges with Entrepreneurship,<br>
Community Action and Humanitarian Spirit</font></i><font face="Arial" size="2">"</font></b></p>
<p align="center"><img border="0" src="images/arilogo-halfsize.gif" width="50" height="56"></p>
<p align="center"><b><a href="jameswormley.htm"><font face="Arial" size="2">Wormley
Recognition</font></a></b></p>
<p align="center"><b><font size="2"><a href="wormley-contribution.htm">Contribution
Form</a></font></b></p>
<p align="center"><b><a href="default.htm"><font face="Arial" size="2">Home</font></a></b></p>
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