BLACKS IN GOVERNMENT
Membership Application

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

Business Address Street: City:

Office Symbol or Mail Stop: State: Zip Code:

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

Membership Number:

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National Membership

Regular chapter dues and 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.

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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:

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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:

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To receive additional information concerning BIG membership , please complete, print-out the above form and mail to the REGION III membership chairperson. If you are renewing your chapter membership, please mail the above form with the correct payment to the local chapter, attn: membership chairperson.

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

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