_______________________________________________________________________

City, State, Zip, Country_____________________________________________________

E-mail:(please print clearly) _________________________________   
Can we publish your email address at our website? YES     NO

Home page URL:_________________________________________

Home phone:__________________________ Home fax:___________________________

Work phone:__________________________ Work fax:_____________________________

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Name when in Peace Corps if different than above:__________________________________________

Country of Peace Corps Service _______________________________

Dates of Peace Corps Service:________________________________

City/town of service:________________________________________

Group #________________ Training site:_______________________

Type of program_________________________

Other Peace Corps service as staff or Volunteer and dates:

____________________________________________________________

Cost: $15 per year to support Ethiopia & Eritrea RPCVs OR $50 per year to join both E&E RPCVs and the National Peace Corps Association (which we strongly urge you to do).

Print and mail this form with your payment to:

Ethiopia & Eritrea RPCVs
c/o Marian Haley Beil,
492 Staten Ave, #1003
Oakland CA, USA