Contact | hauc4u

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Haitian Americans United for Change

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H.N.L.C. Contact and Interest Form

First name*

Last name*

Cell phone*

Mailing address*

Are you a U.S. citizen?*

Yes

No

Have you registered to vote?*

Yes

No

Are you interested in joining the H.N.L.C. movement?*

Yes

No

Do you give an H.N.L.C. member permission to contact you?*

Yes

No

BROOKLYN

5124 Ave N

Brooklyn NY 11234

Phone: 516-451-8226• Fax: 631-285-3863

LONG ISLAND

80 Center Street

Lake Ronkonkoma NY 11779

Phone: 631-352-9492 • Fax: 631-285-3863

Thanks for submitting!

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