Last:                                                     First:                                Middle Initial:

Home Address:

City:                                                      State:                                Zip:

Employer:

Position:

Office Address:

Telephone:    Office:                          Fax:                                 Home:

E-mail Address:

Prefer Mailings Sent to (check one)     Office:                        Home                E-mail

Professional Associations:

Board Memberships:

Honors/Awards:

Education:

State reason for desiring membership in the Metro Columbia Coalition of 100 Black Women:

Describe both personal and professional attributes that may be leveraged by the Metro Columbia Coalition in pursuit of organizational goals and objectives:

(over)

“Committee” Areas of Interest:

Membership/Member Development

Programs/Special Events

Political Education/Advocacy

Health Initiatives/Family Wellness

Education/Community Involvement

Economic Empowerment

Fundraising

Finance

By-Laws/Policies & Procedures

Public Relations

I certify that all information supplied is accurate and complete.

Sign:

Date:

Referring Member Signature:

Date:

Metropolitan Columbia Coalition

Of 100 Black Women

P.O. Box 12112

Columbia, SC 29211