The NCCU Eagle Club

NC Central University Educational Advancement Foundation, Inc.

Post Office Box 792 - Durham, North Carolina 27702-0792

Application of Membership

  MR.() MS.() MRS.() DR.() REV.()

NAME:_____________________________________ ____ ________

Last - First - Middle

ADDRESS: _________________________________________________

CITY:_____________________________________ STATE: _______________________ ZIP Code:_____________________________

Home Telephone:___________________________Work:_________________________

E-mail Address:_____________________________________

Personal Web Page: http://__________________________________________

Are You A: New Member () - Renewing Member () - Life Member () - Other Type Member ()        

Gold Eagle-Life MemberOne Time Gift of $5,000()
Gold EagleAnnual Gift of $600()
Silver EagleAnnual Gift of $300()
Bronze EagleAnnual Gift of $150()
Foundation MemberAnnual Gift of $25-$149()


I Would Like To Make A Special Contribution In The Amount Of: $______________, IN Support of the NCCU Educational Advancement Foundation.

Please Make Your CHECK OR MONEY ORDER Payable To:
(The Eagle Club) NCCU Educational Advancement Foundation.


News Letter () Internet ()
News Media () Eagle Club Member () By Whom: ________________________(Please Specify):

For Additional Information, Please E-mail or Write to:
Roger Burbage at 4605 Limerick Drive, Raleigh, NC 27604-3525

Eagle Club Membership Options

Revised: 04-10-2001

Eagle Club Home Page