PEP REPORTING FORM

Please use this form to submit information to Mississippi Young Bankers for a statewide report on our Personal Education Program (PEP) education efforts.

GENERAL INFO: Your County:
Name of Person Filling Out Report:
Your Bank's Name:
Banker/Instructor's Name (if different from Person Filling Out Report):
Your Bank's City:
Your E-mail Address:
MBA Group Number for Your County (what's this?):
Schoolteacher's Name/Grade (not the name of the banker who taught):
Date of Presentation:
School/Group Name and City:
Students/Adults Contacted (number):
Your Work Phone:
TYPE OF AUDIENCE (please choose one)	Elementary School (K-4)  Middle School (5-8)  High School (9-12) College  Adult  Other
PRESENTATION SETTING (please choose one)	Classroom   School Assembly (large group)  Career Day/Career Fair   Youth Community Group Meeting  Adult Community Group Meeting     Other
YOUR BANK'S ASSET SIZE	Under $25 million  $25 - $49 million   $50 - 99 million   $100 - $499 million   $500 million and over
PRESENTATION MATERIALS (please indicate the title and number of the written program materials, video, speech, etc., used)	Banking on Your Future  Teach Children to Save  Get Smart About Credit  MONEY Video Series  Booklet on Saving  Booklet on Budgeting Booklet on Credit  Booklet on Checking Accounts  Children's Comic/Activity Books  Other (please list/indicate materials used below)

Thank you!