Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Ethnicity

Black or African American

Hispanic

Latino

Asian

Caucasian

Other

Please select the committee that you are interested in volunteering in:

Social & Cultural Development

Membership Engagement

Community Service

Personal & Professional Development

Civic Engagement

I agree to attend at least 2 events per month, i.e. general body or whatever

I agree to volunteer (insert hours) per month