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BLACKS IN GOVERNMENT
Greater Memphis Area Chapter
PO Box 3041
Memphis,TN 38173-0041
Last Name __________________________First Name __________________ Initial _____
Home Phone (________) ___________________
Home Address __________________________________________________________
City_______________________________State________Zip Code__________
Email Address_______________________________________________________
Employed by (spell our Department Agency name):
___________________________________________________________________
Business Address___________________________________________________
City___________________________________State____________Zip Code___________
____ Federal ____ State _____ Local (Identify) ________________________________
Type of Membership: ____ New ____ Renewal Membership Number #:_________________
Name of Chapter: Greater Memphis Area
____Regular Member ____ Associate Member ____ Life Member
National membership dues are 35.00 for regular members and 25.00 for associate members. Chapter dues are established by each Chapter and are payable in addition to National dues. The local dues for the Greater Memphis Chapter are $12. Eligibility for chapter membership is contignet upon national Membership. Life membership fee is 300.00.*
Signature _____________________________________Date __________________, 20____
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CHANGE OF ADDRESS FORM
Name _____________________________________________________________________
Old Address ____________________________________________________________________
City__________________________________State______Zip Code__________
Old Phone Number (____) ____________________
New Address____________________________________________________________
City______________________________State__________Zip Code_________
New Phone Number (____) _________________
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