Membership Report Form

Instructions on completing the PDF membership form:

Click your left mouse in the form field you wish to complete. A cursor will appear and the information can be typed into the proper field. If there is a check-box, simply hit the space bar to place a check in the field. Use the tab key or mouse to navigate to the next field. Make sure you use the proper form for each membership type. Some pages may be blank. Information that remains the same on every page, such as name of Secretary, date, etc., will only need to be typed once and it will be automatically duplicated on subsequent pages. Please save form to your computer to fill out. Printing the PDF membership form: Once the membership form has been completed, go to the File menu and choose the Print menu. Indicate the range of pages you wish to print to avoid printing blank pages. You may need to perform this function several times depending on the kinds of memberships your Branch receives in any given report period. Retain a printed copy for Branch records, and submit a copy to National with your membership share. (You will not be able to save the file with the completed info using Acrobat Reader.)

Instructions to Branch Secretaries

NAACP Membership Dues Sharing Formula with Codes

Membership Type Amount Paid To Unit To National Code

Regular $30.00 $11.90 $18.10 R

Youth w/Crisis $15.00 $4.80 $10.20 T

Youth w/o Crisis $10.00 $3.00 $7.00 U

1. The Branch Constitution (Article V, Sec. 4) requires that allMemberships be reported to the National Office within fifteendays after their receipt in the Branch. It is the duty of theBranch Secretary to see that this is done.

2. All membership reports, whether they contain one (1)membership for one hundred (100), must be made on theregular report forms furnished by the National Office. Do notreport memberships in letters or on other types of stationery.

3. Memberships should be listed in alphabetical order.

4. Complete names and addresses must be given for allmembers. IMPORTANT: TO REPORT CHANGE OFADDRESS PLEASE CHECK THE BOX PROVIDED INADDRESS COLUMN.

Please include E-mail addresses and telephone numberswhen possible.

5. Do not abbreviate names of cities and streets.

6. See that zip codes are indicated for all addresses in yourreports.

7. Keep a record of Membership Numbers obtained frommemberships sent to the Branch. Transcribe the number tothe membership report for each renewal for easier tracking.

8. Enter the Effective Date of each membership in the spaceprovided. To determine effective date, see branch constitution(Article II, sec. 3). If no date appears in this space, the date onthe report will be used.

9. After completing the membership report form and receiving thecheck from the treasurer, make a photocopy of all reports andchecks for accurate records and future concerns.

10.During the various membership campaigns, send a report atleast once a week or every ten days. Do not wait until thecampaign is over to make your reports.

11.When a member complains of failure to get the Crisis, send inthe name and address of that member and the date of thereport in which the membership was remitted to theMembership Department here at the National Office.

12.There are no Mr. & Mrs. Memberships to the NAACP, eachmembership must be listed individually.

13.Make an exact copy of every Membership Report sent to theNational Office. Keep report copies in a loose-leaf notebook, abinder, or on the computer in chronological order.

Instructions for Completing Life Membership Report Forms

Junior Life(Ages 13 and under)

Teen Life(Ages 14 to 20)

(old rate)

Bronze Life(Ages 14 to 20)

Life Membership(old rate)

Silver Life

Golden Heritage(old rate)

Gold Life

Diamond Life

MembershipType

PaymentPlanFull

4 Years

Full5 Years

Full5 Years

Full5 Years

10 Years

Full5 Years

10 Years

Full5 Years

10 Years

Full5 Years

10 Years

Full5 Years

10 Years

AmountPaid

$100.00$25.00

$250.00$50.00

$400.00$80.00

$500.00$100.00$50.00

$750.00$150.00$75.00

$1000.00$200.00$100.00

$1500.00$300.00$150.00

$2500.00$500.00$250.00

ToUnit

$40.00$10.00

$100.00$20.00

$160.00$32.00

$200.00$40.00$20.00

$300.00$60.00$30.00

$400.00$80.00$40.00

$600.00$120.00$60.00

$1000.00$200.00$100.00

ToNat'l

$60.00$15.00

$150.00$30.00

$240.00$48.00

$300.00$60.00$30.00

$450.00$90.00$45.00

$600.00$120.00$60.00

$900.00$180.00$90.00

$1500.00$300.00$150.00

Code

KL

YZ

01

GHH

344

ABB

566

788

1. Name. Enter full name of individual member, business ororganization. If space is not sufficient to enter the entire nameof a business or organization, please abbreviate wherepossible.

2. Address. Indicate address where membership information,the Crisis magazine, and ultimately where the plaque will beshipped. If there are special instructions, attach separatecorrespondence. Complete, legible names of cities andstreets are required. No abbreviations!IMPORTANT: TO REPORT CHANGE OF ADDRESSPLEASE CHECK THE BOX PROVIDED IN ADDRESSCOLUMN.

Please include E-mail addresses and telephone numberswhen possible.

3. Paid By Member. Enter payment made by member in boxmarked A .PLEASE NOTE: The minimum annual life membershippayment should be - Junior Life $25.00; Teen Life (Old Rate)$50.00; Life Membership (Old Rate) $50.00; Silver Life $75.00;Golden Heritage (Old Rate) $100.00; Gold Life $150.00 andDiamond Life $250.00.

4. Unit Portion. Enter the appropriate share retained by theBranch in box marked B .

5. Amount Remitted to National. Enter the appropriatepayment made to National in box marked C .

6. Prior Payments By Member. Enter total Prior Paymentsmade by member in box marked D .

7. Membership Number. If reporting a "renewal" subscribingpayment, enter the membership number found onmembership card.

8. Enter the Effective Date of each membership in the spaceprovided. To determine effective date, see branch constitution(Article II, sec. 3). If no date appears in this space, the date onthe report will be used.

NAACP Membership Dues Sharing Formula With Codes

Junior Life(Ages 13 and under)

Teen Life(Ages 14 to 20)

(old rate)

Bronze Life(Ages 14 to 20)

Life Membership(old rate)

Silver Life

Golden Heritage(old rate)

Gold Life

Diamond Life

MembershipType

PaymentPlanFull

4 Years

Full5 Years

Full5 Years

Full5 Years

10 Years

Full5 Years

10 Years

Full5 Years

10 Years

Full5 Years

10 Years

Full5 Years

10 Years

AmountPaid

$100.00$25.00

$250.00$50.00

$400.00$80.00

$500.00$100.00$50.00

$750.00$150.00$75.00

$1000.00$200.00$100.00

$1500.00$300.00$150.00

$2500.00$500.00$250.00

ToUnit

$40.00$10.00

$100.00$20.00

$160.00$32.00

$200.00$40.00$20.00

$300.00$60.00$30.00

$400.00$80.00$40.00

$600.00$120.00$60.00

$1000.00$200.00$100.00

ToNat'l

$60.00$15.00

$150.00$30.00

$240.00$48.00

$300.00$60.00$30.00

$450.00$90.00$45.00

$600.00$120.00$60.00

$900.00$180.00$90.00

$1500.00$300.00$150.00

Code

KL

YZ

01

GHH

344

ABB

566

788

NAACP Membership Dues Sharing Formula with Codes

Membership Type Amount Paid To Unit To National Code

Regular $30.00 $11.90 $18.10 R

Youth w/Crisis $15.00 $4.80 $10.20 T

Youth w/o Crisis $10.00 $3.00 $7.00 U

NATIONAL ASSOCIATION FOR THE ADVANCEMENT OF COLORED PEOPLE4805 Mt. Hope Drive • Baltimore, Maryland 21215-3297

(410) 358-8900

MEMBERSHIP SUMMARY REPORT

Name of Unit

Date

MEMBERSHIP TYPE TOTALMEMBERSHIPS

TOTALAMOUNT

ADULT(AGES 21 & OVER)

YOUTH W/O CRISIS(AGES 17 & UNDER)

YOUTH W/CRISIS(AGES 20 & UNDER)

JUNIOR LIFE(AGES 13 & UNDER)

TEEN LIFE (OLD RATE)

BRONZE LIFE(AGES 14 TO 20)

LIFE MEMBERSHIP (OLD RATE)

SILVER LIFE

GOLDEN HERITAGE (OLD RATE)

GOLD LIFE

DIAMOND LIFE

ANNUAL CORPORATE

TOTAL

Name of Unit Secretary (Please print) Phone

( )

City State Zip

RETAINEDBY UNIT

REMITTED TO NAT'LOFFICE

Address of Secretary

E-mail AddressUnit Secretary's Signature

Unit Address (City, State, Zip)

ADULT MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People

4805 Mt. Hope Drive • Baltimore, Maryland 21215 Unit No.

Name of Unit DateUnit Address (City, State, Zip)

NAME Paid ByMember

ToUnit

To NationalOffice

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.

Telephone No.Amount remittedherewith

$

$ 11.90 $ 18.10$ 30.00

Name of Unit Secretary (Please print)

Unit Secretary's Signature

(Please fill in Unit No.)

Page of

Membership Number

Effective Date

TOTALS

#

#

#

#

#

Check if new address





E-mail:

E-mail:

E-mail:

E-mail:

E-mail:

FULL ADDRESS ( Include Zip Code)

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

Rev. 3/01




NAME Paid ByMember

ToUnit

To NationalOffice

6.

Telephone No.

7.

Telephone No.

8.

Telephone No.

9.

Telephone No.

10.


$

$ 11.90 $ 18.10$ 30.00




Page of

Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

Rev. 3/01




NAME Paid ByMember

ToUnit

To NationalOffice

11.

Telephone No.

12.

Telephone No.

13.

Telephone No.

14.

Telephone No.

15.


$

$ 11.90 $ 18.10$ 30.00




Page of

Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

Rev. 3/01




NAME Paid ByMember

ToUnit

To NationalOffice

16.

Telephone No.

17.

Telephone No.

18.

Telephone No.

19.

Telephone No.

20.


$

$ 11.90 $ 18.10$ 30.00




Page of

Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

Rev. 3/01




NAME Paid ByMember

ToUnit

To NationalOffice

21.

Telephone No.

22.

Telephone No.

23.

Telephone No.

24.

Telephone No.

25.


$

$ 11.90 $ 18.10$ 30.00




Page of

Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

Rev. 3/01




NAME Paid ByMember

ToUnit

To NationalOffice

26.

Telephone No.

27.

Telephone No.

28.

Telephone No.

29.

Telephone No.

30.


$

$ 11.90 $ 18.10$ 30.00




Page of

Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

$ 11.90 $ 18.10$ 30.00

Rev. 3/01

YOUTH MEMBERSHIP W/O CRISIS REGISTRATION FORMNational Association for the Advancement of Colored People

4805 Mt. Hope Drive • Baltimore, Maryland 21215

Only Available to Individuals Ages 17 and Under

Unit No.


$ 3.00 $ 7.00$ 10.00


Page of

NAME Paid ByMember

ToUnit

To NationalOffice

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00




Unit No.


$ 3.00 $ 7.00$ 10.00


Page of

NAME Paid ByMember

ToUnit

To NationalOffice

6.

Telephone No.

7.

Telephone No.

8.

Telephone No.

9.

Telephone No.

10.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00




Unit No.


$ 3.00 $ 7.00$ 10.00


Page of

NAME Paid ByMember

ToUnit

To NationalOffice

11.

Telephone No.

12.

Telephone No.

13.

Telephone No.

14.

Telephone No.

15.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

$ 7.00$ 3.00$ 10.00

YOUTH MEMBERSHIP WITH CRISIS REGISTRATION FORMNational Association for the Advancement of Colored People



Unit No.


$ 4.80 $ 10.20$ 15.00


Page of

NAME Paid ByMember

ToUnit

To NationalOffice

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00




Unit No.


$ 4.80 $ 10.20$ 15.00


Page of

NAME Paid ByMember

ToUnit

To NationalOffice

6.

Telephone No.

7.

Telephone No.

8.

Telephone No.

9.

Telephone No.

10.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00




Unit No.


$ 4.80 $ 10.20$ 15.00


Page of

NAME Paid ByMember

ToUnit

To NationalOffice

11.

Telephone No.

12.

Telephone No.

13.

Telephone No.

14.

Telephone No.

15.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

$ 10.20$ 4.80$ 15.00

JUNIOR LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO INDIVIDUALS AGES 13 & UNDER.

Unit No.


$ 25.00$ 100.00

$ 10.00$ 40.00

$ 15.00$ 60.00


Page of

60% ToNational

OfficeNAME Paid By

MemberTo

Unit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:

FULL ADDRESS (Include Zip Code)

Rev. 3/01

A B C

$ $ $

$Prior paymentsmade by member�

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

$ 15.00$ 60.00

$ 10.00$ 40.00

$ 25.00$ 100.00

$ 15.00$ 60.00

$ 10.00$ 40.00

$ 25.00$ 100.00

$ 15.00$ 60.00

$ 10.00$ 40.00

$ 25.00$ 100.00

$ 15.00$ 60.00

$ 10.00$ 40.00

$ 25.00$ 100.00

TEEN LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO INDIVIDUALS AGES 14 TO 20WHO BEGAN PAYMENT PRIOR TO APRIL 1, 1999

Unit No.


$ 50.00$ 250.00

$ 20.00$ 100.00

$ 30.00$ 150.00

60% ToNational

Office


Page of

NAME FULL ADDRESS (Include Zip Code) Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:

A B C

$ $ $D


$ 50.00$ 250.00

$ 20.00$ 100.00

$ 30.00$ 150.00

A B C

$ $ $


$ 50.00$ 250.00

$ 20.00$ 100.00

$ 30.00$ 150.00

A B C

$ $ $


$ 50.00$ 250.00

$ 20.00$ 100.00

$ 30.00$ 150.00

A B C

$ $ $


$ 50.00$ 250.00

$ 20.00$ 100.00

$ 30.00$ 150.00

A B C

$ $ $


D

D

D

D

BRONZE LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO INDIVIDUALS AGES 14 TO 20.

Unit No.


60% ToNational

Office


Page of

NAME Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

$ 80.00$ 400.00

$ 32.00$ 160.00

$ 48.00$ 240.00

$ 48.00$ 240.00

$ 32.00$ 160.00

$ 80.00$ 400.00

$ 48.00$ 240.00

$ 32.00$ 160.00

$ 80.00$ 400.00

$ 48.00$ 240.00

$ 32.00$ 160.00

$ 80.00$ 400.00

$ 48.00$ 240.00

$ 32.00$ 160.00

$ 80.00$ 400.00

LIFE MEMBERSHIP ($500.00) REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO MEMBERS WHO BEGAN PAYMENT PRIOR TO APRIL 1, 1999

Unit No.


$ 50.00$ 500.00

$ 30.00$ 300.00

60% ToNational

Office


Page of

NAME Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


$ 20.00$ 200.00

$ 30.00$ 300.00

$ 20.00$ 200.00

$ 50.00$ 500.00

$ 30.00$ 300.00

$ 20.00$ 200.00

$ 50.00$ 500.00

$ 30.00$ 300.00

$ 20.00$ 200.00

$ 50.00$ 500.00

$ 30.00$ 300.00

$ 20.00$ 200.00

$ 50.00$ 500.00

D

D

D

D

D

SILVER LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People



$ 75.00$ 750.00

$ 30.00$ 300.00

$ 45.00$ 450.00

60% ToNational

Office


Page of

NAME Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

SILVER LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People



$ 75.00$ 750.00

$ 30.00$ 300.00

$ 45.00$ 450.00

60% ToNational

Office


Page of

NAME Paid ByMember

ToUnit

6.

Telephone No.

7.

Telephone No.

8.

Telephone No.

9.

Telephone No.

10.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

$ 45.00$ 450.00

$ 30.00$ 300.00

$ 75.00$ 750.00

GOLDEN HERITAGE LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO MEMBERS WHO BEGAN PAYMENT PRIOR TO APRIL 1, 1999

Unit No.


60% ToNational

Office

$ 100.00$ 1000.00

$ 40.00$ 400.00

$ 60.00$ 600.00


Page of

NAME Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

$ 60.00$ 600.00

$ 40.00$ 400.00

$ 100.00$ 1000.00

$ 60.00$ 600.00

$ 40.00$ 400.00

$ 100.00$ 1000.00

$ 60.00$ 600.00

$ 40.00$ 400.00

$ 100.00$ 1000.00

$ 60.00$ 600.00

$ 40.00$ 400.00

$ 100.00$ 1000.00

GOLD LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO FULLY PAID LIFE ($500) OR SILVER LIFE MEMBERS

Unit No.


$ 150.00$ 1500.00

$ 60.00$ 600.00

$ 90.00$900.00

60% ToNational

Office


Page of

NAME Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

$ 90.00$900.00

$ 150.00$ 1500.00

$ 60.00$ 600.00

$ 90.00$900.00

$ 150.00$ 1500.00

$ 60.00$ 600.00

$ 90.00$900.00

$ 150.00$ 1500.00

$ 60.00$ 600.00

$ 90.00$900.00

$ 150.00$ 1500.00

$ 60.00$ 600.00

Unit No.


$ 250.00$ 2,500.00

$ 100.00$ 1,000.00

$ 150.00$ 1,500.00

60% ToNational

Office


Page of

NAME Paid ByMember

ToUnit

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$



Membership Number

Effective Date

TOTALS

#

#

#

#

#






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:


Rev. 3/01

A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


A B C

$ $ $


D

D

D

D

D

DIAMOND LIFE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People


ONLY AVAILABLE TO FULLY PAID GOLDEN HERITAGE OR GOLD LIFE MEMBERS

$ 150.00$ 1,500.00

$ 100.00$ 1,000.00

$ 250.00$ 2,500.00

$ 150.00$ 1,500.00

$ 100.00$ 1,000.00

$ 250.00$ 2,500.00

$ 150.00$ 1,500.00

$ 100.00$ 1,000.00

$ 250.00$ 2,500.00

$ 150.00$ 1,500.00

$ 100.00$ 1,000.00

$ 250.00$ 2,500.00

ANNUAL CORPORATE MEMBERSHIP REGISTRATION FORMNational Association for the Advancement of Colored People



Please circle each amount pertaining to the new member


Page of

NAME FULL ADDRESS ( Include Zip Code) Paid ByCorporation

ToUnit

60% ToNational

Office

1.

Telephone No.

2.

Telephone No.

3.

Telephone No.

4.

Telephone No.

5.


$

$ 2000.00 $ 3000.00$ 5000.00



Membership Number

Effective Date

TOTALS

#

#

#

#

#

Rev. 3/01






E-mail:

E-mail:

E-mail:

E-mail:

E-mail:

$ 2000.00 $ 3000.00$ 5000.00

$ 2000.00 $ 3000.00$ 5000.00

$ 2000.00 $ 3000.00$ 5000.00

$ 2000.00 $ 3000.00$ 5000.00

Membership Report Form

Education

Transcript of Membership Report Form