GC/MV Membership Application

Blacks In Government
Greater Cincinnati/Miami Valley Chapter
527 Horse Branch Road
Edgewood, KY 41018

Name Last: First: Initial:

Home Address Street: P. O. Box:

City: State: Zip Code:

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

Department Employed By: Agency: Other:

Business Address Street: City:

Office Symbol or Mail Stop: State: Zip Code:

Type of Membership: Name of Chapter: Greater Cincinnati/Miami Valley Chapter

Membership Number:

National Membership

Regular chapter dues and national membership dues are $47.00 for a Regular membership, $37.00 for an 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.

Change of Address Form

Old Information

Name Last: First: Initial:

Home Address Street: P. O. Box:

City: State: Zip Code:

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

New Information

Name Last: First: Initial:

Home Address Street: P. O. Box:

City: State: Zip Code:

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

To receive additional information concerning Greater Cincinnati/Miami Valley chapter membership , please complete, print-out the above form and mail to the chapter membership chairperson. If you are renewing your chapter membership, please mail the above form with the correct payment to the Greater Cincinnati/Miami Valley chapter membership chairperson.

Please do not mail cash. Payment in U. S. currency only.

If you will require any additional information concerning membership in the Greater Cincinnati/Miami Valley chapter

Membership Chairperson: Alan Harris