Monticello Avenue Member Organization Application

Please review our hosting services and member responsibilities at http://avenue.org/host.htm . If you have questions before you apply for an account with Monticello Avenue, please contact the Coordinator at webmaster@avenue.org or call (434) 979-7151 x 202.  Please print, then complete this form and return it to our office.
Name of Organization:

 
Federal Tax Exempt ID (required):

 
Address of Organization:

 
City, State: Zip Code:
Phone#:

 

 Fax#:
Account Manager (person who will maintain the home page):
Account Manager's Address:

 
City, State:

 

 Zip Code:
Phone#:

 

 Fax#:
Email:
Contact Person (officer/leader of group - serves as additional contact): 
Contact Person's Address:

 
City, State:

 

 Zip Code:
Phone#:

 

 Fax#:
Email:
As an official representative of 

 ____________________________________________________________
I understand and will abide by the policies established by the Jefferson-Madison Regional Library Board of Trustees and agree to notify Monticello Avenue of any changes affecting this account.
Signed:
Date:
Office Use Only:

____ Data Base         ____ Directory

____ ID                     ____ Mailing List

____ Password          ____ Notify 
Please
submit to:
 Stella B. Pool
Monticello Avenue Coordinator
Jefferson-Madison Regional Library
201 E. Market Street,
Charlottesville, Virginia 22902
(434) 979-7151 ext. 202
fax (434) 979-9728
webmaster@avenue.org