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
                  495 Grand Blvd., Suite 206
                  Miramar Beach, FL 32550

Level

PAN AFRICAN CULTURAL HERITAGE SOCIETY MEMBERSHIP APPLICATION

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