VCA Membership Application

Membership Application
(Please print all information)

I. Membership Information

Name (first, middle initial, last)

Organization

Street Address

City/State/Zip/Country

Area Code Telephone (If international, include country and city codes)

Area Code Fax (If international, include country and city codes)

Signature / Date

II. Membership Category

Please indicate your membership category of interest:

General/*Charter Member ($50) (*If in Yr 2001)
Associate Member ($25)
Student Member ($15)
Individual Lifetime Member ($1000)
Corporate - Sustaining Member ($500)

III. Donation $___________

IV. Payment of Fees

All payments must be remitted in US$. Do not send cash. Payment must accompany registration form.

Membership effective upon receipt
Fees payable on a calendar year basis
VCA is an IRS Section 501 (c) 3 organization

Check / Money Order Enclosed (Make payable to Virginia Coalition For Africa)

V. Mail to:

Virginia Coalition For Africa
P.O. Box 3348
Hampton, Virginia 23663-0348
ATTN: Membership Office