WHAT IS THE PURPOSE OF THIS PROGRAM



REPORT/RENEWAL

Due 90 days after delivery or by date specified in delivery packet

Today’s Date: __________________

|Partner Organization Name: |      |Tribe Name: |      |

|Address: |      |Office Phone #: |      |

|City, State, Zip: |      |Office Fax #: |       |

|Primary Contact: |      |Alternate Phone #: |      |

| | |(other than office number) | |

|Title: |      |Email address: |      |

What are the needs of the program so we BETTER support you? ______________________________________________

__________________________________________________________________________________________________________

Do you have any suggestions for other Activity services or supplies? ________________________________________

__________________________________________________________________________________________________

Do you have any referrals, questions or comments about the Activities Service or any other PWNA Services? ____________________________________________________________________________________________________________________________________________________________________________________________________________

For another delivery for this service please provide the following information:

Next Activity? (circle all that apply): Arts/Crafts Sewing Recreation/Games Other

How many people are interested in participating in the next activity? __________

| | | |

|Program Partner Primary Contact Signature | |Date |

Disclaimer: Products provided by Partnership With Native Americans (PWNA) CANNOT be sold or distributed to promote any type of Tribal business (i.e. elections, meetings, campaigns, etc.). If at any time, PWNA is informed that a Program Partner and/or program volunteers have used the products in such manner, PWNA will be forced to drop the Program Partner.[pic][pic][pic][pic]

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Project Participated In (circle all that apply): Arts/Crafts Sewing Recreation/Games Other

Number of people that participated in the activities: _______________

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1310 E. Riverview Dr. Phoenix, AZ 85034

Tel: 602-340-8050 * Toll Free: 877-281-0808 * Fax: 602-340-8055

Rev 06/15

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