Membership Application - Women In Rural

Email *

First Name *

Last Name *

Address *

Address

Line 1

Line 2

City

State/Province

Zip/Postal

Would you like your address listed? *

Phone *

Employer *

***please note if self employed

Employment Status

Size of Employer

Industry *

How did you hear about Women In Rural?

What is your biggest professional challenge doing business in your area? *

What is your biggest personal challenge living in your area? *

1 - Not Interested 3 - Indifferent 5 - Very Interested

Contributing to site and WIR *

The opportunity to share personal and professional knowledge through Women In Rural's (WIR) blog, newsletter, and social media.