National Congress of Black Women Membership Form

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Yes, I want to become an active member of the NCBW and join the crusade to

empower African American women and their communities.

How did you hear about The National Congress of Black Women_______________________

Desired Membership Category:

____ $25 Young Adult (up to age 25)

____ $50 General (Youth Membership $10.00 (up to 21 yr.)

____ $100 Patron

____ $200 Sponsor

____ $500 Benefactor

____ $1000 Life Membership

I am unable to become a member at this time. Please accept my contribution of $______.

I wish to pay by ___ cash ___ check ___ credit card (Amex/Visa/MC)

Credit Card #: __________________________________ Exp. Date: _____________

Signature of Approval: _______________________________ Date: _____________

Make checks payable to: The National Congress of Black Women

Mail application to: The National Congress of Black Women

1251 4th Street, SW,

Washington, DC 20024

Phone: 202/678-6788

Full Name: _____________________________________

Email: _______________________________________________________________

Street: ______________________________________________________________

City: ___________________________ State: _______ Zip Code: ______________

Phone: ___________ Fax: ___________

Other Organizations or Affiliations:

____________________________________________________________________

Are you a registered voter? ____ Yes ____ No

Political Party: ____ Democratic ____ Republican ____ Independent ____ Other