For National Office Use Only

Name Last:
First: Initial:

Home Address Street:
P. O. Box:

Home Phone Number Area Code Number:
Business Phone Number Area Code: Number:

Department Employed By: Federal Local State None Other Agency: Department of the Air Force Department of the Army Department of Commerce Department of Defense Department of Energy Department of the Navy Department of the Interior Department of Veterans Affairs General Accounting Office Social Security Administration U. S. Army Corps of Engineers Other Retired
Other:

Business Address Street:
City:

Type of Membership: Regular (New) Regular (Renewal) Associate (New) Associate (Renewal) Life Membership (Full Payment) Life Membership (Installment Payment)
Name of Chapter:

E-Mail Address:

I would like to receive electronic correspondence from BIG: Yes No

National Membership

National membership dues are $35.00 for a Regular membership, $25.00 for a Associate membership, and $300.00 for a Life membership .

Chapter Membership

Chapter dues are established and payable to the chapter. Eligibility of chapter membership is contingent upon payment of National membership dues to the chapter. Each chapter will collect all national dues and forward same to the National Office of BIG.

We encourage all Blacks In Government members to become an active member of a chapter within their Region.

Change of Address Form

Old Information

Name Last:
First: Initial:

Home Address Street:
P. O. Box:

Home Phone Number Area Code Number:
Business Phone Number Area Code: Number:

New Information

Name Last: First: Initial:

Home Address Street:
P. O. Box:

Home Phone Number Area Code Number:
Business Phone Number Area Code: Number:

Please print-out the above form and mail, with the correct payment to the national office of Blacks In Government. If you are renewing your chapter membership, please mail the above form with the correct payment to your chapter membership chairperson.

Type of Payment method: Check:   Money Order:   Purchase order:   

Credit card:      If you are paying by credit card, you can fax ([202] 667-3705) your membership form to the national office of Blacks In Government and Ms. Peggy Downing will contact you to obtain your credit card number and expiration date.

Please: do not fax or mail your credit card number or expiration date.

If you are paying BIG national membership dues, your completed membership form will be forwarded to the Regional Council President in the state which you reside and they will contact you about chapter membership within your city.