MEMBERSHIP APPLICATION

BLACKS IN GOVERNMENT

Dallas Metroplex Chapter

PO BOX 223583

Dallas TX 75222-3583

 

Name Last First

Home Address:

Street

City State

Zip Code

Home Number/Area Code

 

Employed By: Federal State Local Other

Department / Agency / Other

(Do not abbreviate)

Business Phone #

Street

City State

Zip Code

E-mail address:

Membership Dues

(1) Life Member: $300.00 National ($25.00 due annually to chapter)

(2) General Member: $60.00 ($35.00 National $25.00 Chapter due annually)

(3) Associate Member: $35.OO ($25.00 National $10.00 Chapter due annually)

Chapter dues are established by each Chapter and are payable in addition to National dues. Eligibility for chapter membership is contingent upon National membership.

 

 
  New

Renewal membership number

 

Change of Address Form

Name LastFirst

Home Address Street

City State

Zip Code

Home Phone Number Area Code

Business Number Area Code

 

Please do not mail cash.

Membership Signature

If you require any additional information concerning membership

PRINT APPLICATION

Mail to: Dallas Metroplex Chapter of Blacks In Government,P.O. Box 223583, Dallas, TX 75222-3583 

Or bring your application to the next meeting

 

IT’S TIME TO

THINK BIG

Download Application