Membership Application Form

Henry-Clayton Section National Council of Negro Women Membership Application

Impacting the Community Through the Purple Power Collective!
Website

www.henryclaytonncnw.org
Zelle

financecommhenryclaytonncnw@gmail.com
Mailing Address

PO Box 414 Stockbridge, GA 30281
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Home Number
Format: (000) 000-0000.
Cellular Number*
Format: (000) 000-0000.
Date Joined*

MonthDayYear
Date
Birthday*
Month and Day
Professional Expertise*
Affiliate Organization Membership
Affiliate Organization Membership
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Format: (000) 000-0000.
Annual Membership $150.00 ($75 National Dues and $75 Section Dues)Life Membership $1000.00 (One Time Payment or 4-$250.00 Installments)Legacy Life Membership $1500.00 (One Time Payment or 4-$375.00 Installments)Associate $75 (Support) (Men Only)
Economic Empowerment and EntrepreneurshipSTEAM (Education)Health EquityMembershipBy-LawsOutreachHospitalityWays and MeansMedia/TechnologySocial JusticeYACA Committee
Additional Information
Questions

If you have any questions about membership please email 2vphcncnw@gmail.com. If you have any questions regarding dues submission, please email finsec.hcncnw@gmail.com and cc financecommhenryclaytonncnw@gmail.com
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Henry-Clayton Section National Council of Negro Women Membership Application