PAN AFRICAN CULTURAL HERITAGE SOCIETY MEMBERSHIP APPLICATION

I wish to join as a

☐ Small Business/Professional for $100/yr     ☐ Community Organization for $50/yr      ☐ Individual for $25/yr

 
Contact Name: _______________________________________________________________________________

Company/Organization Name: __________________________________________________________________

Address: ____________________________________________________________________________________

Phone/Fax: _________________________________________________________________________________

Email: _____________________________________________________________________________________

Website: ___________________________________________________________________

Society Joining (optional - please provid
e Network Partner code, S-09 for example, if desired)      ____ - _______

Referred by (name/organization): ________________________________________________________________

Payment Information

(note – membership can be paid online via PayPal following the link below)

Type of Credit Card: Visa ☐      MasterCard ☐

Name on Credit Card: ___________________________________________

Credit Card #: ____________________________________          Expiration Date: ______/_______

Security Code____________________

Billing Address for Credit Card: __________________________________________________________________

                                                  __________________________________________________________________

By electronically signing below, I authorize my membership fee to be charged to this card.

 

Signature: _____________________________________________Date ______________________


Email completed application to: PanAfrica@NBBSC.org

                                           ***************************************************************************

If you prefer to pay by check, make payable to the National Black Business Support Corporation

MAIL TO:   National Black Business Support Corporation
                  Attn: Society Membership
                  113 S. Monroe Street
                  Tallahassee, FL 32301

Level
The plans of the diligent lead to profit as surely as haste leads to poverty. - Proverbs 21:5