Name of Organization

Name

Email Address

Street Address

City

State/Province

Postal /Zip Code

Phone Number (Day)

Phone Number (Evening)

Fax Number

Organization’s Officers And Membership Information

Presidents Full Name

Vice Presidents Full Name

Secretarys Full Name

Treasurers Full Name

Total Number of Organization Members?

How many chapters comprise your organization?

In which countries are your affiliates located?

Is your organization affiliated with any statewide consortium? Is your organization affiliated with any statewide consortium? Yes No

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

Indicate how your organization can contribute to the mission of NJBIC?

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:

Full Name:

Name of Alternate NJBIC representative:

Full Name:

Membership Fee (Required)