Literacy Coalition of Central Texas

Please print out this application form and mail to:

Literacy Coalition of Central Texas

Attn: Membership

P.O. Box 41567

Austin, TX 78704-1567

Title______________________________________________________________

Charitable Registration Number________________________________________

Name of Primary Contact Person_______________________________________

Project Coordinator__________________________________________________

Exceutive Director___________________________________________________

Street Address______________________________________________________

City_______________________________________________________________

County_____________________________________________________________

Zip Code___________________________________________________________

Email______________________________________________________________

Phone Number_______________________________________________________

Fax Number_________________________________________________________

Website____________________________________________________________

Date of first provision of literacy services_________________________________

Type of services provided (i.e., ESL, GED, Basic Literacy, Family Literacy, Adult Basic Education, Workplace Literacy, Computer Literacy, Other). Please list all that apply.

___________________________________________________________________

___________________________________________________________________

Average number of students served annually______________________________

Days and hours of operation____________________________________________

Please include the following with your application: 1) Documentation of 501 (c) 3 status if application. 2) List of Board Members with addresses and phone numbers 3) Annual Membership fee ($25)