New York City Environmental Justice Alliance Membership Form

Print out this form........or download a PDF file...or a DOC file and mail to:
New York City Environmental Justice Alliance
271 West 125th Street
Suite 303
New York, NY 10027
or Fax to

Member Organizations’ Membership Application

Name of Organization: _______________________________





Phone:____________________ Fax: ___________________

Name of Contact Person(s) and Title(s): ___________________, ___________________

Do you have an Email address? Yes No Email: ___________________________

Do you have a Web Site Address? Yes No Web Site: ________________________

Number of Paid Staff: _______ Number of Volunteers:______ Number of Members:______

What year was your organization started/founded? _____________

Are you a 501(c)(3) tax-exempt organization? Yes No

Neighborhoods Served:______________________________________________

Community Board(s):______________________________________________

Languages Spoken:______________________________________________

Is this a community-based organization? Yes No

Does your organization have members? Yes q No

What are the criteria for becoming a member of your organization?


Brief Description of Organization(100 words max.):

(Please Include Mission Statement, Why the organization was started, or include additional materials that state this information.)









Information Profile Update — page 1 of 3

NYCEJA is a network led by people of color - please complete the following chart as part of our commitment to maintain this organizing principle.

Diversity Profile of the Organization:


List of Directors Staff Members African






Specific Issues or Program/Project Focus:

Solid Waste___Water___ Air Pollution___

Transportation q Health;_____ Lead____

Open Space & Age-specific (seniors, children, young people)

Government Policy (local, state, or federal)

Other ______________________________________________


Lobbying/Advocacy___ Education ___ Services___

Research___Direct Action____(Please see below)

Organizing____Other ___________________________________

Resources that your organization offers to the community/ies:

Workshops/training ___ Technical Assistance ___ Research (e.g. legal) ___

Resource Center q Outreach ___

Information materials ___ Other __________________________________

Computer Mapping ___

What kind of resources can NYCEJA offer your organization?

Type of Resources & Specific Needs

Workshops/training _____________________________________________

Technical Assistance _____________________________________________

Research (e.g. legal) _____________________________________________

Computer Mapping _____________________________________________

Information materials _____________________________________________

Lobbying & Advocacy _____________________________________________

Networking or outreach with other NYCEJA and non-NYCEJA members ___

Notices of relevant meetings, policies, legal actions, etc. ___

Other _____________________________________________

Information Profile Update - page 2 of 3

List the organizing campaigns and advocacy work that your organization has done in the past 3 years (e.g., public education, government lobbying, community events, etc.):





Is your organization involved in (present or past) any other grassroots coalitions/networks?

Yes ___ No ___

If yes, please list the coalitions that your organization is a member:


Information Profile Update - page 3 of 3