NON Charter Application Form

For all new National Outreach Network Charter applicants.

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Statement of Nondiscrimination

In compliance with Federal, State, and local Equal Employment Opportunity laws, qualified applicants are considered for all positions without regard to race, color, creed, religion, ancestry, sex, national origin, pregnancy, affectional preference, age, physical handicap or disability, veteran status, marital status, or status with regard to public assistance.
Contact Information
Primary Contact
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Please provide the best phone number to reach you.

NON Charter Information
Do you anticipate your SAVE Charter representing a city or region?
- City
- Region
For example, "Honolulu, HI SAVE Charter" represents the city limits of Honolulu. "Central New York SAVE Charter" represents a greater area that encompasses many cities within a specified area of Central New York and is considered a region.
What city or region do you anticipate your charter representing?
Please list the city or region and the US state your SAVE NON Charter will represent.
Why do you want to organize a SAVE NON Charter?
In 300 words or less, please tell us why you would like to start a National Outreach Network Charter in your area.
How did you hear about SAVE?
- Google search
- Facebook
- Twitter
- Instagram
- From a friend or family member
- Other

NON Charter Members
Please list the names and county of residence of up to six other charter members. While not required, we find it best that survivors participating in this level of suicide prevention have passed the one year anniversary of the loss of their loved one.
1. Name
First Last
County of Residence
County
2. Name
First Last
County of Residence
County
3. Name
First Last
County of Residence
County
4. Name
First Last
County of Residence
County
5. Name
First Last
County of Residence
County
6. Name
First Last
County of Residence
County

SAVE