COLUMBUS AREA CHAPTER

MEMBERSHIP APPLICATION

 

NAME: ____________________________________________________________________________

 

ADDRESS:_________________________________________________________________________

                          STREET                                                                        CITY/STATE                                                                  ZIP

 

 

GOVERNMENT EMPLOYEE (PLEASE INDICATE LEVEL)

 

___FEDERAL       ___STATE             ___COUNTY        ___MUNICIPAL         ___MILITARY

 

                 ___PUBLIC EDUCATION       ___RETIRED       ___SEEKING EMPLOYMENT        __OTHER

 

 

EMAIL:____________________________________________________________________

 

HOME PHONE:_____________________________  

 

BUSINESS PHONE________________________(I CAN___CANNOT___BE CONTACTED AT WORK)

 

 

 

I HEREBY APPLY FOR MEMBERSHIP IN THE

COLUMBUS AREA CHAPTER OF BLACKS IN GOVERNMENT

 

ENCLOSED IS $50.00 FOR FULL PAYMENT OF ANNUAL DUES

($35.00 NATIONAL, $10.00 LOCAL, $5.00 REGION)

 

Please make check or money order to: COLUMBUS AREA CHAPTER OF BIG

 

 

 

 

______________________________________________________________________________

NEW MEMBER SIGNATURE                                                                                                               DATE

 

 

MAIL TO:   Columbus Area Chapter - BIG

                         MEMBERSHIP CHAIRPERSON (D. Willis)

                         PO BOX 132509

                         COLUMBUS, OHIO 43213

 

 

EFFECTIVE ____/____/____                                                          TYPE OF MEMBERSHIP

                                                                                                                    

                                                                                                                     REGULAR _____

                                                                                                                    ASSOCIATE_____

 

Columbus Area Chapter

Of Blacks In Government

We must begin somewhere to ensure our future...

CHAPTER REGISTRATION

Please print, complete and mail registration fee(s) and form

for membership into the Columbus Area Chapter of BIG.