Concerned Black Clergy of Metropolitan Atlanta, Inc.

Membership Application

CBC Membership Application Please complete one application per person
Full Name:
Address:
City:
State:		Zip:

Church/Mosque Temple/Organization:
Preferred Telephones:
Email:
Membership Type: (check one)
Individual - $50
Church/Mosque/Temple/Organization - $100
Coporate - $1000
Senior Citizen - $20
Student - $20
Additional Pledges/Commitments:
$100
$75
$50
Other (indicate amount)
Committees:
Health	Activities of Interest:
Education	Salute Banquets
Economic Development	Health Walks
Juvenille Justice	Others:
Media/Publication
Membership
Public Safety
Voter Registration/Education/Mobilization
Please Type your Full Name in leux of signature