CBC Lifetime Membership Application

Carolina Black Caucus Lifetime Membership Application

To apply for lifetime membership please complete all questions. Lifetime Membership is subject to approval by the CBC leadership team.
Name*

First NameLast Name
Title/Role
Dept./Unit/Organization
University Affiliation

FacultyStaff/AdministrationUNC Alumni (not currently employed at the University)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Cell Number*
Membership Type
prevnext( X )
Lifetime Membership
$500.00
Statement of Interest - Please let us know what you desire to gain from and/or hope to accomplish as an active lifetime member of the Carolina Black Caucus.*
Would you like to participate on a committee? Please indicate your choices below.

FundraisingSignature/Social EventsNominations and AwardsMarketingAdvocacy
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Carolina Black Caucus Lifetime Membership Application