LOCAL COORDINATOR
PROPOSAL
 




Proposed Location (Town, City, County)   __________________

Name(s) of Proposed Local Coordinator(s):  ___________________________________

______________________________________________________________________________

Organization(s): _____________________________________

Mailing 
Address______________________________________________________________________

______________________________________________________________________________

Phone:    ____________			TTY: ____________________________________

FAX:   	____________	Email: ___________________

Other Contact Info:  ____________________________________________________________

______________________________________________________________________________

Relationship between organization's mission and NDMD: 
______________________________________________________________________________

_________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________________


Preliminary Members of Local Organizing Committee (with Organizations): ____________

_____________________________________________________________________________

______________________________________________________________________________

Target group(s):     ____ High School Students      _____ College Students     
_____ Job Seekers

Estimated Number of Mentees: ___________

Proposed Date(s) of Activities: __________________________________________

___________________________________________________________________

Proposed Type of Activities (e.g., one-on-one shadowing, group visits, plenary gatherings): 




______________________________________________________________________________
_-
_____________________________________________________________________________

_______________________________________             	___________________
Signature(s)								Date