USDA Rural Development Rural Workforce Innovation Networ

USDA Rural Development Rural
Workforce Innovation Network (RWIN)
Membership Form
Thank you for your interest. To join the Rural Workforce Innovation Network, please complete
this form and click the “Submit” button at the bottom of this screen. If you have any questions,
please send an email with "RWIN Membership" in the subject line to:
R [email protected].

* Required

OMB No. 0503-0024

Expires 04/30/2023

1. Date: *
Please input date in format of M/d/yyyy

2. Name of Organization *
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3. Address: *
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4. City *
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5. State or Territory *
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6. Zip Code *
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7. Website URL (if applicable)
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8. First Name *
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9. Last Name: *

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10. Email Address: *
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11. Phone Number: (Optional)
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12. The following demographic questions will allow us to better understand you, our
network audience, and also identify gaps in membership reach. This information
will help us tailor future outreach strategies.
Organization Type: *
Non-profit
Public (Local, State, Federal, or Tribal Government)
Private Business
Education
Other

13. Organization service area: *
Nationwide
Statewide
Multiple States (please select "Other" and list states)

Regional Specific (please select "Other" and list regions)
Local (please select "Other" and list localities)
Other

14. By checking this box, I give permission for USDA to use the name of this
organization in Rural Workforce Innovation Network materials for public audiences
including fact sheets, resource guides and websites created by USDA.
USDA is an equal opportunity provider, employer, and lender.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0503-0024. The time
required to complete this information collection is estimated to average 3 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.
I give permission

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