To become a member of Fathers' Rights of Nebraska, please fill out and mail in the form below.

First Name:	*
Last Name:	*
Sex:	*
Age:	*
Email Address:	*
Address:	*
City:	*
State:	*
Zip:	*
Home Phone:
Work Phone:
Cell Phone:
How did you hear about us?	Referred by a member   Read an ad, flyer, or card Radio Television Other
What is your main reason for joining?	I want/deserve to be with my children more I support all of your goals I support some of your goals and believe fathers who are fit and able deserve equality Fathers in Nebraska have been discriminated against for far too long and a change is long overdue I believe this is best for children All of the above Other

Are you willing to take an active role in our organization?	*	Are you a registered voter in the state of Nebraska?	*
Fathers' Rights of Nebraska 7914 West Dodge Road #310 Omaha, NE 68114		OR fax it to: 391-DADS (3237)