Membership Application And
Renewal Form

Women's Mining Coalition

Applicant Name:	New Member Renewing Member
Personal Email:
Home Phone:
Cell Phone:
Home Address:
City:
State:
Zip Code:
Zip + 4:
Company:
Position
Work Email:
Office Phone:
Work Address:
City:
State:
Zip Code:
Zip + 4:

What is your congressional district for your home address ?	Find your Congressional District
What is your congressional district for your work address?
In which sector of the mining industry do you work?	Coal Hardrock Industrial Minerals Utility/Energy/Service Mining Intelligence & Technology Environmental Control Manufacturing Other
Are you interested in participating in the WMC Annual Fly-In to Washington, D.C.?	yes, please send me more information no
May we publish your contact info in our online members-only directory? Your information will be available only to WMC members for networking opportunities.	Yes No