 |  |  |  |  |  |
Please Print Clearly:
FIRST NAME: ______________________________________ LAST NAME:__________________________________________
SPOUSE’S NAME (If also applying for membership):_________________________________________________________________
ADDRESS__________________________________________________________________________________________________
Street City/State Zip Code
TELEPHONE NO:________________________________________CELL:_______________________________________________
E-MAIL ADDRESS:___________________________________________________________________________________________
WHO MAY WE THANK FOR REFERRING YOU TO THE YWCJCC:_____________________________________________________
MEMBERSHIP CRITERION: Yes, I/We are dedicated & support the Mission of the Coalition: Check To Confirm: _____________
MEMBERSHIP DUES: $10 Per Person for one full year of membership.
OR
If $10 is beyond your means, any contribution amount will qualify for membership.
MEMBERSHIP AMOUNT PAID: (Indicate below the total amount of membership dues being paid and the total number of persons).
$10 per person: $_________________ (1) ____________ or (2) ____________
Total Amount Check No. of Persons
CONTRIBUTION AMOUNT MADE: (In addition to Membership Payment, contributions are always welcome and are tax deductible).
If you also wish to make a contribution at this time, please indicate the amount: $ _________.
TOTAL AMOUNT PAID : (Dues & Contribution, if any): $_______; Check Payment Method: Cash ______; or Check_____ & No. ______
_____________________________________________________________ ________________________________________
Signature Date
_____________________________________________________________ ________________________________________
Signature (Spouse if also applying) Date
| Yes We Can Johnston County Coalition, Inc. A Coalition of Concerned Citizens |
| What we do by ourselves matters; What we do together really makes the difference. |
MEMBERSHIP IN THE YWCJCC Membership Dues are $10 and extends for 12 Months Sole Criterion is being committed to the mission of the Coalition. This Form may be printed off your computer and submitted by mail. |
******************************************************************************************************************************************************************************************************************
 |  |  |  |
| Make Check payable to: YWCJCC Mail Check and Membership Form To: Kristin M. Williams, Secretary YWCJCC 2121 Powell Drive Clayton, North Carolina 27520 |
MEMBERSHIP FORM