Group:   CPSR/___________________________

Mission Statement

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________



IF the  Group is based upon producing specific events or products:

1- Provide a reasonable deadline date for CPSR approval: _______________  and
2- attach a timeline with the major milestones of the project.



Please list the names of your Group officers, the dates their terms
of office expire, and the email and mailing addresses, and phone numbers by which
they can be contacted on CPSR business.



Chair:  ______________________________________

Term Expires:_____________

Phone:  ( _____ ) _________________________ (work)

( _____ ) __________________________ (home)

Mailing Address:  ______________________________________

______________________________________

Email:   ______________________________________



Secretary:    ______________________________________

Term Expires:_____________

Phone:   ( _____ ) _________________________ (work)

( _____ ) __________________________ (home)

Address:   ______________________________________

______________________________________

Email:   ______________________________________



Treasurer:   ______________________________________

Term Expires:_____________

Phone:   ( _____ ) _________________________ (work)

( _____ ) __________________________ (home)

Address:   ______________________________________

______________________________________

Email:   ______________________________________


Also please supply information about your regular meetings (if any), giving
schedule and location.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________




CPSR Group Formation Petition

Please fill in the following petition, print and sign you names, and
submit to:  CPSR, 1370 Mission St., 4th floor, San Francisco, CA 94103 by mail or
+1 415-839-8617 by fax (call 415-839-9355 to confirm before faxing), or
cpsr-board@lists.cpsr.org by PDF attachment.  
If the petition is approved, an email confirming your status as
an official Group will be sent to the address given in item 3, below.





Date:   _____________________

We, the undersigned members of Computer Professionals for Social
Responsibility, Inc. (CPSR), hereby propose to establish a Group of
CPSR.  The Chapter/Working Group will be dedicated to the purposes of Computer
Professionals for Social Responsibility, Inc., and will conduct its
business and organization in accordance with CPSR's policies and by-
laws.



1.The Group shall be known as CPSR/______________________ (fill
in with an appropriate geographic or subject designation, such as 'Seattle',
'Japan', or 'Privacy').



2.  The Group shall have as initial officers

Chair:   ________________________________________

Secretary:      ________________________________________

Treasurer:      ________________________________________

Other Officers (if desired):         ___________________________

_______________________________________



3.  The following address shall be used by potential members who wish to contact
this Group.  This Information will be printed on the chapter information page
circulated by the national office and  placed in each issue of the national
Newsletter:


Contact:   ______________________________________

Term Expires:_____________

Phone:   ( _____ ) _________________________ (work)

( _____ ) __________________________ (home)

Address:   ______________________________________

______________________________________





Your Names (please print and sign):

Signature:

1.________________________

____________________________

2.________________________

____________________________

3.________________________

____________________________

4.________________________

____________________________

5.________________________

____________________________

1370 Mission St., 4th floor
San Francisco, CA 94103
Phone: (415)839-9355
Fax: (415)839-8617 E-mail cpsr@cpsr.org