NASA LANGLEY ACTIVITIES ASSOCIATION - ELIGIBILITY CERTIFICATION

I hereby certify that I am eligible to participate in the NASA Langley Activities Association league/club based on (please check the applicable status):

_____ Employment with/Retirement from NASA

_____ Spouse/Dependent of NASA Langley employee (sponsored participation)

_____ Employment with NASA Langley contractor

_____ Spouse/Dependent of NASA Langley contractor (sponsored participation)

Fill in your name, if you are a NASA/contractor employee, or the name of the NASA/contractor employee sponsoring your participation:

_______________________ _______________________ _________________

Name of Employee NASA Organization?company Employee Phone Number

Check the NASA Langley league/club in which you will participate:

___ Aerobics Club ___ Amateur Radio Club ___ Astronomy Club

___ Basketball Club ___ Bassmasters Club ___ Bowling League

___ Conservation Club ___ Flag Football League ___ Garden Club

___ Golf League ___ Karate Club ___ Radio Model Club

___ Runners Club ___ Science Fiction Club ___ Softball League

___ Tennis League ___ Volleyball League

Participant’s Name ____________________________________(Please print)

Participant’s Address: ________________________________________________

(Mail Stop/Street Address) (City) (State) (zip)

E-Mail Address _________________________ Work Telephone _____________

Home Telephone ____________

Signature _________________________________ Date ___________________

 

 

Page Curator: Scott Angster (s.r.angster@larc.nasa.gov)

NASA Official Responsible For Content: Latunia Melton (latunia.p.melton@larc.nasa.gov)