AFRAM Membership Form 2024

SEIU National African American Caucus (AFRAM)

MEMBERSHIP APPLICATION
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Phone*
Please enter a valid phone number.
Region in PA:*

CentralEasternSouthernWestern
Retiree or new?

RetireeNew generation of leaders
Local Chapter*
City & State*
Annual Dues

Annual dues are $15. Membership is on a year-to-year basis (January through December). All payments will be considered for the year submitted only.
Payment Options:

Pay via CashApp

Or

Mail Check or Money Order To:

SEIU HCPA ℅ SHARMIKA PERRY
1500 N 2ND STREET
HARRISBURG, PA 17102

Keep your receipt as proof of payment
Payment Options: (Choose one)*

CashappMail Check or Money Order
Should be Empty:

SEIU National African American Caucus (AFRAM)