Post Office Box 792 - Durham, North Carolina
27702-0792
E-mail: lmh1300@verizon.net
Application of Membership
MR.() MS.() MRS.() DR.() REV.()
NAME:_____________________________________
____
________
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 Member | One Time | Gift of $5,000 | () |
Gold Eagle | Annual | Gift of $600 | () |
Silver Eagle | Annual | Gift of $300 | () |
Bronze Eagle | Annual | Gift of $150 | () |
Foundation Member | Annual | Gift of $25-$149 | () |
*SPECIAL CONTRIBUTION*
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
Revised: 04-10-2001