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
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Cell Number
Format: (000) 000-0000.
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.
Should be Empty:

Carolina Black Caucus Lifetime Membership Application