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.

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

1224 W. Street, SE, Suite 200

Washington, DC 20020

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