Please fill out the following and ensure that all information is complete.

Organization/Neighborhood Name:*

Year Established:*

Represents:*

Single-family households Commercial Properties

Multi-family households Vacant Lots

Organization/Neighborhood Boundaries (North, South, East & West):*

List Schools, Parks &/or Churches within the boundaries:*

Is Your Organization/Neighborhood: Please check all that apply.*

HOA Block Watch

Governed by Management Company

If governed by a Management Company, please provide contact information in the spaces below:

Representative Name:

Management Company:

Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Telephone Number:

Fax Number:

Email Address:

General Information:

Primary Contact:

Name:

Mailing Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Telephone Number:

Email Address (All Contact Persons must indicate a valid email address at which to receive neighborhood notification.):

Secondary Contact:

Name:

Mailing Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Telephone Number:

Email Address (All Contact Persons must indicate a valid email address at which to receive neighborhood notification.):

Board Members:

President:

Vice-President:

Secretary:

Organization Web Address:

Meetings:*

Monthly Annual

Other

General Meeting Location:

Meeting Time:

Newsletter or Other Publication:

List of concerns, comments, questions or suggested topics for planning workshops:

All information provided is a matter of public record & will be released to third parties upon request.