WBAI Local Station Board

1. Name and Contact information (including address, email, phone numbers)


NAME ________________________________________________   EMAIL ADDRESS __________________________________________


ADDRESS ________________________________________________  CITY _________________________   STATE ____   ZIP ________


HOME PHONE ____________________________________  WORK PHONE ___________________________________


2. Are you applying to be a listener representative on the committee or a staff representative? (circle one)     
     Listener           Staff


3. Please provide a brief explanation of why you want to be a member of the committee.






4. Any other information that you think is relevant or that the committee should know. (If you think you may have a conflict of interest being on this committee or you have some special skills and/or background that make you suitable for this task, this is the place to tell us about it.)








E-Mail to WBAI-LSB-Public-owner@yahoogroups.com, OR
Please print out mail forms and snail mail them so that we receive them by September 7, 2009, to:

WBAI Local Station Board
att: Mitchel Cohen, Chair
120 Wall Street, 10th floor
NYC 10005