Join BWLC

Membership Form

Xerox Employees, Friends of BWLC and Ally
Payroll Deduction is available to all Xerox employees. "Friends of BWLC" memberships are available via Paypal.
Date Joined

MonthDayYear
Name*

First Last
E-mail*
example@example.com
Phone (000-000-0000)
Address (City & State / Province are required)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Payment Method*

Payroll Deduction (Xerox Employees)PayPal (non-Xerox Employees)
Member Level - Payroll Deduction

$25: Xerox Woman of Color Employee$35 BWLC Ally$0 Xerox EMEA Employee
Membership Level - Pay Pal
prevnext( X )
Friends of BWLC$35.00
Employee ID
Employee Status

ExemptNon-Exempt
Division or Organization
Title
Job Field
Years of Service
Friends of BWLC

Xerox RetireeContractorFamily MemberFriendOther
Education Level
Age Range
Birth Month
Birth Day
How would you like to serve in BWLC?
How did you hear about the BWLC?*
BWLC Chapter*

WEST: California & Northwest Region (incl. AK, AZ, CA, HI, ID, MT,NV, OR, UT, WA, WY)WEST: Central Southwest Region (incl. CO, NM)MID: Central Southwest Region (incl. AR, KS, LA, MO, NE, OK, TX)MID: Midwest Region (incl. IA, IL,IN, MI, MN, ND, SD, WI, Ontario, CA)EAST: Mid-Atlantic Region (incl. DC,DE, MD, VA, WV)EAST: Monroe County (incl. Buffalo)EAST: Northeast Region (incl. CT,KY, MA, ME, NH, NJ, NYC, OH, PA, RI, VT)EAST: Southeast Region (incl. AL,FL, GA, MS, NC, SC, TN)EMEA: Europe, Middle East & Africa
Please verify that you are human*
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Membership Form