Jan-Dec
20ʹͳ
Extension Connection Subscription Building Strong & Vibrant New York Communities
www.sullivancce.org
I am a full time resident of Sullivan County I am a seasonal resident from ____________________ to ______________________
*Name:____________________________________________ Company:__________________________________________
____________________________________________________ *City:___________________ *State:_______ *Zip:__________ *Phone:______________________________________________ E-mail:_______________________________________________ CCESC Community Group:_______________________________
*Required
CCESC has my permission to use photos of me for marketing and educational purposes. New Enrollee
Renewal
I would like to receive my Extension Connection Magazine via:
1 Year
__ I would like to make an additional contribution to Cornell Cooperative Extension in the amount of:
$_____________
Total Amount Enclosed:
Cash Amount:
Please select all that apply to you. Ethnicity & Race
Asian Black/African American Hispanic/ Latino/a Native American/ American Indian Other Pacific Islander White/ Caucasian
Gender Identity Female Male Gender Not Listed
$_____________
FOR OFFICE USE ONLY Date Deposited:
Agriculture & Food Systems Community & Economic Vitality Environment & Natural Resources Nutrition & Healthy Families Youth & Family Development
Demographic data is an important tool that informs our organization about our members so that we can better serve the people of Sullivan County. This information is maintained in a secure database and only used for reporting and program planning purposes. This is optional.
Demographics
Payment Information
E-mail saves important funds for programming.
Demographic Data (OPTIONAL)
Donation $25.00
I am a weekend resident I am retired I am a student I am a(n) _________________________________ farmer I am a veteran I don’t live in Sullivan County but I work or visit often
What programs would you like to receive opportunities for (check all that apply)? Interests
Contact Information
*Address:____________________________________________
Pay by cash, check, or credit (online/office). Please make checks payable to CCESC Mail to: 64 Ferndale-Loomis Road Liberty, NY 12754 CALL 845-292-6180 E-MAIL sullivan@cornell.edu
Check Amount & #:
VISIT www.sullivancce.org
Diversity and Inclusion are a part of Cornell University’s heritage. We are a recognized employer and educator valuing AA/EEO, Protected Veterans, and Individuals with Disabilities.
Extension E t Connection C t
December 2020
Page 9
