BAN Join Form

Join the Basel Action Network!

Please print and fill out this form, then fax it to 1-206-652-5750 or mail it to:

The Basel Action Network
122 S. Jackson Street, Suite 320
Seattle, WA 98104
USA

Organization Name:

___________________________________________________

Contact Person:

___________________________________________________

Position:

___________________________________________________

Mailing Address:

___________________________________________________
___________________________________________________
___________________________________________________

E-mail:

___________________________________________________

Website:

___________________________________________________

Phone:

_______-________-___________________________

Fax:

_______-________-___________________________

Please note, this form is NOT for those who are interested specifically in our e-waste program, the e-Stewards Initiative. If you are a company seeking to become a part of the e-Stewards Initiative, please visit www.e-Stewards.org for instruction.

Organization Name:	___________________________________________________
Contact Person:	___________________________________________________
Position:	___________________________________________________
Mailing Address:	___________________________________________________ ___________________________________________________ ___________________________________________________
E-mail:	___________________________________________________
Website:	___________________________________________________
Phone:	_______-________-___________________________
Fax:	_______-________-___________________________