EmailMe Form - Membership Form - Ella Baker Leadership Circle

Name: *

Prefix First Last Suffix

Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email: *

Membership Type: *

Class Year: *

If alumna please enter 4-digit class year, e.g., 1973.

Regular Membership Amount *

Regular Member ($1,000 annually)

Special Membership Amount: *

Special Member ($500 annually)

Special membership includes faculty and staff members and their spouses along with current students and recent graduates (graduated in the past five years)

PAYMENT OPTIONS

Payment Type: *

One-Time Payment

Recurring Payment

Membership Payment *

$1,000 Annually (Regular Member)

$500 Annually (Special Member)

Frequency: *

Two Installments

Monthly Payments

We will process your membership payment until paid in full unless notified otherwise.

Frequency day: *

Process payment on the 1st day of the month

Process payment on the 15th day of the month

Initial Installment Amount: *

$150

$250

$500

MATCHING GIFT

If matching gift, please check:

If your company participates in a matching gift program, please request and complete the appropriate form from your personnel office.

Company Name:

ADDITIONAL INFORMATION

Would like to receive occasional email updates from the University? *

Yes, I would like to receive occasional emails

No, not at this time.

University Code: