BLACK FAMILIES ASSOCIATION
0f CONTRA COSTA COUNTY


                 APPLICANT NAME SPOUSE NAME                                                 
                
   BIRTHDAY    /    /                                  BIRTHDAY   /      /


                  STREET                                              CITY                                          STATE                 ZIP CODE

                
   EMAIL ADDRESS


                 WORK PHONE        HOME PHONE


      OPTIONAL
              CHILDREN NAMES(S)                            AGE



                                        NOTE: LIST ADDITIONAL CHILDREN ON SEPARATE SHEET OF PAPER









  _______
Membership dues expires June 30 of each year

Make you check or Money Order Payable To:

      BLACK FAMILIES ASSOCIATION
P.O. BOX 21481
CONCORD, CA 94521
                  925 680 2849
DATE ___/___/____SIGNATURE _________________

        MEMBERSHIP APPLICATION
** FAMILY $40.00            PER YEAR

** SINGLE $25.00           PER YEAR

STUDENTS $7.00         PER YEAR

* Family plan consists of parent & children under 18
TOTAL NUMBER OF FAMILY MEMBERS (including applicant)
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