Club Membership Registration Form

CPG,INC - OHBCUD Registration Form

Complete the form below to sign up for our membership service.
Name

First NameLast Name
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Membership Category

Institutional (HBCU or PBI) $700Administration/Faculty/Staff $25Attending Student (HBCU or PBI) $10Alumni (HBCU or PBI) $20Fraternity/Sorority Organization $200Community Org Rep Local Area $40General Donation (HBCU/PBI) $15 min. request
PLEASE FILL IN SECTION THAT APPLIES TO YOU!
NAME/STATE OF HBCU OR PBI NOW EMPLOYED, ATTENDING OR COMPLETED:
Name
City
State
Membership Category Checked Above
(A) CURRENT STUDENT & RANK AT HBCU OR PBI: (FEE = $ 10 ANNUAL)
CURRENTLY ENROLLED AS:

UndergradGrad Student
Major at HBCU/PBI:
Expected Graduation Date
(B) ALUMNI/GRADUATE OF HBCU OR PBI: (FEE = $ 20)
Was Enrolled As:

UndergradGrad Student
Major at HBCU/PBI:
Graduation Date
Degree Earned

BachelorsMastersDoctorate
(C) REPRESENTATIVE OF LOCAL COMMUNITY ORGANIZATION: (FEE = $ 40)
NAME OF ORGANIZATION:
Title
City
State
(D) CURRENT EMPLOYEE - TITLE/POSITION AT HBCU OR PBI: (FEE = $ 25 ANNUAL)
Title/Position
(E) INSTITUTIONAL MEMBERSHIP: ($700 annual fee)
Title
HBCU or PBI Name:
City:
State:
(F) Fraternity/Sorority Name:
Fraternity/Sorority Name:
City:
State:
(G) General Donor (Non-HBCU/PBI) ($15 min. request)
I want to donate

$15Other
Donation

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USDEnter Donation Amount
Once you submit your application, we will contact you shortly to confirm your payment and membership.

Thank you!

CPG,INC - OHBCUD Registration Form

PLEASE FILL IN SECTION THAT APPLIES TO YOU!