Group/Organization Listing Form

Print this form and fax to (317) 639-4297 or mail to:

Diversity Inc.
P.O. Box 441473
Indianapolis, IN 46244-1473

Group Name _________________________________

All fields below are optional; however, we must have an e-mail address or phone number for verification purposes.

Contact at Organization (if applicable):_________________________________

Address:______________________________

City:_________________________________

State:_______ Zip____________

Phone Number________________________

Fax Number__________________________

Toll Free_____________________________

E-Mail Address _________________________________

Web Address: http://______________________________

Write a brief description of your group:__________________________________________

________________________________________________________________________

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