NON Charter Application Form Please complete the following application to begin the New NON Charter process. NON Charter Application Form For all new National Outreach Network Charter applicants. Step 1 of 3 33% 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 InformationPrimary Contact* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* PhonePlease provide the best phone number to reach you. NON Charter InformationDo you anticipate your SAVE Charter representing a city or region?CityRegionFor 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 MembersPlease 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