Please print out the application, complete and mail to the following address:

Take Charge Partnership
P. O. Box 4893
Pittsburgh, PA 15206

Date:____________ Name:_________________________________________

Organization/Company/Affiliation:_______________________________

Professional Title/Degrees (if applicable):_____________________

Address 1:______________________________________________________

Address 2:______________________________________________________

City:_____________________________ State:________ Zip:__________

Work Tel:________________________ Home Tel:_____________________

Cell Phone:______________________ eMail: _______________________

Do you wish to be subscribed to the email listserve?
______ Yes ______ No

Attached is:
Check ____Cash _____ in the amount of $_________________________

Check the appropriate selection:
donation ____; membership ____; donation and membership ____

(Minimum membership fee $10.00. Additional gifts gratefully accepted!)
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Informational Demographic Data (optional):

I heard about Take Charge from:_________________________________

The primary reason I am joining/renewing Take Charge is:
________________________________________________________________

Briefly list skills/area of expertise/experience regarding end of life interests:
________________________________________________________________
________________________________________________________________
________________________________________________________________