Membership Application

Your Name

Which describes your role at ��ý?

Faculty member

Classified professional

Administrator

Please indicate your status

Full-time

Part-time

What is your job title?

What is your department?

What is your office phone extension

What is your mobile phone number? (optional)

What is your email address?

How many years have you worked at ��ý?

Please select your committee interest. (You may select more than one)

African American High School Student Conference

Martin Luther King Jr.

Black History Month

Black Graduation and Achievement Ceremony

Membership and Nomination

Any comments or questions?

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