North Central Region, Fiscal Year
NATIONAL COUNCIL ON BLACK AMERICAN AFFAIRS
 American Association of Community Colleges
INDIVIDUAL MEMBERSHIP APPLICATION

INSTRUCTIONS: Please complete this form online, keying in all of the requested information. Tab between boxes. When completed, print two (2) copies (non-draft mode), sign both copies, and mail one copy, with check (do not send cash), to the Treasurer, NCBAA/North Central Region:
Dr. Maurice H. McCall
Post Office Box 430148
Pontiac, MI 48343-0148
 mccallm@ncbaa.org
Membership Status

(Check One):



Prefix
First Name
MI
Last Name
Suffix
Position Title
Department or Office
Name of Institution
Campus
Office Address
Office Telephone
Office Fax
Office City
State
ZIP
Preferred E-mail Address
Home Address
Home Telephone
Home Fax
Home City
State
ZIP
Alternate E-mail Address


My check (Payable to NCBAA/NC)
is enclosed, as follows:		 Check No.
Amount
Signature



___________________________ 		Date
PLEASE DO NOT WRITE BELOW THIS LINE
Recd by Regional Treasurer (Signature) Date

 Recd by National VP for Membership (Signature) Date
Card No.

 Issued by Date Check No. Bank ID Dated
Regional membership fees include national NCBAA membership.  The membership year is July 1 to June 30.  NCBAA, PO Box 267, Yuba City, CA  95991-9998; white-danielss@ncbaa.org. (Form Revised March 25, 2003, webmaster@ncbaa.org)