Author: Yvette Williams

Membership Application
clarkcountyblackcaucus@gmail.com / ccblackcaucus.com
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Pay online and email your completed application or
Make check payable to: Clark County Black Caucus and
mail to 2960 Redwood St., Las Vegas, NV 89146
(Please Print Clearly)
By completing this application and remitting my membership dues, I express my desire to participate as an active member in the CCBC and do attest that I am currently registered to vote in Clark County, Nevada or will do so when eligible. I have read the CCBC Code of Conduct on the website and agree to uphold the standards as set forth by it’s membership.
_____________________________________ Date: ___________
Signature
10/14

Administrative Use ONLY
___ $35 Member Dues ___ $125 Alumni Dues ___ $275 Lifetime Membership Dues
Dues Rcvd $ ________  Cash  Check Date Rcvd _______ By _____________
 Input  Committee Assignment  Treasurer  Membership  Recording Secretary

Name:	E-Mail: / Birthday: (Month/Day)
Phone: / Cell ________________________ / Home ________________________	Address: / City: / Zip Code:

Committee Sign Up
I understand that the success of the Black Caucus is determined by the level of involvement of it’s members and agree to serve on a minimum of one action committee. Therefore please sign me up for the following committee(s).
Finance  Political Action  Community Outreach/Faith
(Fundraising) (Legislative/Policy)  Economic Empowerment
Education  Social Media/Technology  Youth (After School)
Health/Wellness  Justice Issues  Membership
r Child Welfare r Ex-Offender/Prison Reform q Leadership/Precinct Captain