Northeast 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/Northeast Region:
Dr. Roy H. McLeod
43-10 Kissena Blvd., Suite 15N
Flushing, NY 11355
 royhugh@rcn.com
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/NE)
is enclosed, as follows:		 Check No.
Amount
Signature



___________________________ 		Date
PLEASE DO NOT WRITE BELOW THIS LINE
Recd by Regl VP/Membership (Signature) Date

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

 Issued by Date Check No. Bank ID Dated
Fees include national membership. The membership year is July 1 to June 30. Membership, NCBAA, PO Box 267, Yuba City, CA  95991-9998, white-danielss@ncbaa.org; or, to Dean Yvette C. Urquhart, York College, 94-20 Guy R. Brewer Blvd., Jamaica, NY 11451, urqyc@cunyvm.cuny.edu. (Rev. 03/28/2003) [Back to Membership]