EmailMeForm
MNWT Intent to Extend
This form is used to notify the state that your chapter will be doing an extension.
Responses to the online form will be viewed by your district director, the state extension director, and the state president. Fill in as much information as you know. Upon completion of the form, click Submit; you will receive a confirmation screen if your form has been successfully submitted. (rev 2015)
Submission Date
*
MM
/
DD
/
YYYY
Your Email
*
District
*
Please select
District 2
District 3
District 4
District 5
District 6
District 7
District 8
District 10
District 11
Chapter
*
Community
*
Enter the name of the town that your chapter is willing to make a commitment to assist and support the new chapter for a minimum of two years
Approval Date
*
MM
/
DD
/
YYYY
Enter the date approved by chapter or Extension team
By whom have you been approached?
*
Have you set meeting date(s)?
*
Yes
No
Meeting Dates
*
Since you said you had set up meeting date(s), please enter the date(s)
Informational Meeting Organizer Name
*
Who will be organizing the first Information meeting?
Extension Assistant Names
*
Who will be assisting with this Extension?
Extension Chair Name
*
First
Last
Enter the name of Extension Team Chair
Extension Chair Email
*
Extension Chair Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Extension Chair Phone
*
###
-
###
-
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Chapter President or Another Extension Team Member Name
*
First
Last
Enter the name of President or another Extension Team Member
Chapter President or Another Extension Team Member Email
*
Chapter President or Another Extension Team Member Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Chapter President or Another Extension Team Member Phone
*
###
-
###
-
####
Chapter State Delegate or Another Extension Team Member Name
*
First
Last
Enter the name of State Delegate or another Extension Team Member
Chapter State Delegate or Another Extension Team Member Phone
*
###
-
###
-
####
Chapter State Delegate or Another Extension Team Member Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Chapter State Delegate or Another Extension Team Member Email
*
Other Pertinent Information
Enter any other pertinent information
Would you like to receive the Extension Manual & Extension Media Kit from the US Women of Today ?
*
Yes
No
