UNITED PARENTS AGAINST LEAD NATIONAL, INC. (UPAL NATIONAL)
STATE/LOCAL CHAPTER REQUEST FORM


Name: __________________________________________________

Address: ________________________________________________

________________________________________________

Race/Nationality __________________________________________
(FOR STATISTICAL PURPOSES)


Phone: ______________________ Fax: _______________________

E-mail: ___________________________________________________

Parent of a Lead Poisoned Child Yes_____ No _____

I hereby request information and/or assistance on establishing a United Parents Against Lead (UPAL) Chapter in the State of ______________.

________________________________ _______________________
(Signature Required) (Date)

Return this form to: Zakia Rafiqa Shabazz
United Parents Against Lead (UPAL)
P.O. Box 24773
Richmond, VA 23224

FAX: (804) 562-5031

Thank you for your interest in UPAL and your desire to protect children from the devastating effects of lead poisoning and other environmental hazards.

A CHILD IS A TERRIBLE THING TO WASTE!

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UPAL Office Use Only:
Date request received in UPAL Office ______________________________
State Contact Person: ___________________________________________
Parent(s) of Lead Poisoned Child(ren)
State Site Visit Planned ____ Yes ____ No __________Date
Materials Mailed or Delivered _______________Date
Incorporation Letter Received _____________Date
State Chapter # _____ Under Umbrella of UPAL National