Kildare PPN Membership Registration Form

Part A - Details of Organisation

1.
A. Organisation Details


URL

Name of Organisation

Address of Organisation

 

 

Town   

County   

Website Address

Twitter Address or Handle

Facebook Address or Page

Email Address for Organisation

Confirm you can be contacted primarily by email   
Main means of communication in the future will be via social media/email - so it is important to supply Email address

 

B. Main Contact Person


Name1st Name: Surname:

Contact Address

 

 

Town   

County   

 

Telephone No.

Mobile No.

Email Address

 

2.
Brief Description of Organisation and Activities


 

 

3.
Complete as appropriate:


Chairperson name1st Name: Surname:

Secretary name1st Name: Surname:

Treasurer name1st Name: Surname:

4.
When was Organisation set up?         Month:         Year:    


5.
Year of last AGM                         


6.
Does your organisation have any of the following?

Constitution    Articles of Association    Written Guidelines    None of These

7.
Number of members in organisation

 

8.
If Affiliated to other Umbrella Group Please specify:

9.
Is your group providing services Countywide?     Yes     No

 

10.
Electoral College or Pillar


What is the main focus of your Organisation? Please tick, as appropriate

Community & Voluntary ( local development, sports, social groups ) Click for detailed criteria

Social Inclusion (focussed on people experiencing disadvantage & inequality) Click for detailed criteria

Environmental (focussed on protecting the environment & sustainable development) Click for detailed criteria

 

11.
Municipal District (Electoral Area)

Which is most appropriate to your organisation? (See Map)


Athy

Celbridge-Leixlip

Maynooth

Kildare-Newbridge

Naas

 

Part B - Complete only if it applies to your Organisation

Number of staff employed in org:     Number of Volunteers:

Number on C.E/Job Bridge/TUS :

 

Part C - Representative or Alternate to County Kildare PPN Plenary

If your organisation expects to attend any meetings of the PPN, please indicate below, main representative/alternate, who will attend.

 

Representative

Name

1st Name

Surname

Address

Town
County

Phone

Mobile

Email

 

Alternate

 

1st Name

Surname

 

Town
County

 

 

 

 

Part D - Declaration

I understand that data supplied on this form can be used to send information about County Kildare Public Participation Network (PPN) and its activities, and other items which the PPN considers may be of interest to PPN organisations in Kildare. I understand that this application is subject to validation before registration is completed. I confirm that the information supplied on this membership registration form is correct.

Name:     Position in Organisation: