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1. Organisation Details

Tell us about your organisation and it's aims: Select the Cause that most closely represents the work of your organisation: Select the Pilar that most closely represents the activities of your organisation: Groups Structure: If Other please describe: The Geographical area you operate in: Electoral Area of your main base: Number of people involved in your organisation: Year Established: Facebook Page:
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2. Main Address For Correspondence

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3. Main Contact Details

Are you the Main Contact for this Organisation?


Will you be the representative or the alternative for your organisation in relation to the PPN?:
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4. Alternative Details

Alternate First Name: Alternate Surname: Alternate Mobile: Alternate Email:

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Organisation Details


Tell us about your organisation: Address Line 1:
Address Line 2:
Address Line 3:
Eircode (if available):
Select the Pilar that most closely represents the activities of your organisation:
Geographical area your group covers:
Electoral Area of your main base:
Select the Cause that most closely represents the work of your organisation:
Date Established:
Group's structure:
If other group structure, describe:
Number of paid staff in org:
Number of volunteers in org:
Number of other staff in org:
Number of members in org:
Is Membership open to everyone:

Facebook page:

Details of Main Contact of Organisation







Details of Alternative Contact


Alternate Contact First Name:
Alternate Contact Last Name:
Alternate Contact Phone:
Alternate Contact Mobile:
Alternate Contact Email:
*=Required