NJBIC MEMBERSHIP APPLICATION

Link to download membership form is at the bottom of this page.

Download the new jersey black issues convention organization membership application pdf

New JERSEY BLACK ISSUE CONVENTION MEMBERSHIP

Note: All online orders require the membership fee to be paid via credit card.

If you choose to download and print your application it MUST be accompanied with a check or money order in the amount of $150.00 made payable to the New Jersey Black Issues Convention (NJBIC) in order to be considered for membership in NJBIC.

Name of Organization

Organization Contact Information

Name

First Name Last Name

Address

Street Address Street Address Line 2 City State/Province Postal /Zip Code

Phone Number (Day)

Please enter a valid phone number.

Phone Number (Evening)

Please enter a valid phone number.

example@example.com

Fax Number

Please enter a valid phone number.

Organization’s Officers And Membership Information

President

First Name Last Name

Vice President

First Name Last Name

Secretary

First Name Last Name

Treasurer

First Name Last Name

Total Number of Organization Members:

How many chapters comprise your organization?

In which countries are your affiliates located?

Country

Is your organization affiliated with any statewide consortium?

Yes

Explain why your organization is interested in becoming a member of the new jersey black issues convention:

A. Indicate how your organization can contribute to the mission of NJBIC

B. What type of statewide projects has your organization undertaken?

What type of statewide projects/issues does your organization recommend NJBIC undertake in the future?

Name of Designated NJBIC representative:

First Name Last Name

Name of Alternate NJBIC representative:

First Name Last Name

Membership Fee(Required)