WILLING TO RUN / CONTACT INFORMATION FORM

I hereby declare my candidacy for election as a petition candidate to the National Space Society Board of Directors.

Position (choose one only):

        ___ At-Large seat
        ___ Regional seat for Region ___

Name (as you wish it to appear on the ballot):


Address:


Phone:


Email:


Signature:







[This form is required. To be valid, all items on this form must be filled out.]