Black Radical Congress: Membership Form

Membership Form

Join the BRC

Any individual who identifies her or himself as Black (African or African-descended), and agrees with the BRC Principles of Unity, is eligible for membership in the Black Radical Congress. Please print this form, fill it in (type or print clearly), and return to the address below. You may also download this form in PDF format.

   Name____________________________________________

Address____________________________________________

   City_______________________ State____ Zip_______ 

Phones (1) _______________ (2) _____________

   Fax _____________________________

 Email _____________________________

Organizing Committee (if applicable) _______________


Please provide the following information

1. Date of Birth ______________

2. Occupation _____________________________________

3. Which BRC Caucus(es) would you like to join?

 ____ Working/Labor ____ Youth   _____ Feminist

 ____ Lesbian/Gay/Bisexual/Transgender   ____ International

4. What other political groups do you belong to?
   ________________________________________________

5. Please indicate the arena(s) of struggle/issues
 which you want to work on:

 National areas of work
 ( ) Anti-Police State
	[ ] Mumia Abu-Jamal
	[ ] Assata Shakur
	[ ] Other ____________________________

 ( ) Economic Justice       ( ) Public Education
 ( ) Reparations            ( ) Health Care
 ( ) Electoral Reform       ( ) Violence
 ( ) Housing/Gentrification ( ) Welfare 
 ( ) Affirmative Action     ( ) Culture 
 ( ) Labor Organizing       ( ) Drugs
 ( ) Education Reform

6. Please list some of your skills, talents, or resources 
   that could help build the BRC. 




7. Please check the appropriate amount for your Yearly
 Dues:

   ___ $1.00    Unemployed
   ___ $10.00   Fixed Income (students, seniors, low income)
   ___ $25.00   General 
   ___ $25.00   Friend of the BRC (non-Black supporter)
   ___ $50.00+  Sustainer
   ___ $TBD	Affiliate Organization (contact National Organizer for info)
                


Signature __________________________ Date __________

Please mail with your check or money order for the amount specified above to the National Office:

BRC National Office
P.O. Box 24795
St. Louis, MO 63115