Membership Application

(asterisk * denotes a required field)

Please provide the following information then click the CONTINUE button:

*Mr./Ms.*	* First Name: * Last Name:
* Mailing Address:	*Floor/Suite:*
* City:	* State: * Zip Code:
*Profession/Title:*
*Company Name:*
*Work Phone:*	*Home Phone:*
*Fax Number:*	*E-mail:*
*Date of Birth:*	-- (mm/dd/yy) *Date:* Monday, May 15, 2006 10:58 PM

* Please select membership category then click the CONTINUE button:

Select Category

Active ($25.00) General ($50.00) Professional ($100.00)

Patron (enter an amount between $100.00 - $500.00) Corporate (enter any amount over $500.00)

Senior Citizen ($15.00) Student ($15.00)

Enter any amount over $500.00

Enter total amount

Enter amount between $100.00 - $500.00

* Enter Membership Fee:	$
(optional) Amount of additional donation:	$
	---------------------
* Enter total amount:	$

* Please select your method of payment:

* (Click on your choice)


CREDIT CARD	CHECK	PLEDGE
*Please complete the form below*	*Mail your check to the address below*	*A pledge reminder will be sent to you*

Enter name on card

Enter card number

Enter expiration date

Select type of card

Thank You

You have chosen to pay your membership fee by credit card:

Please complete this form then click the CONTINUE button:

             Enter total amount

* Amount to be Charged:

$

* Credit Card:


* Cardholder's Name:

* Credit Card Number:

* Expiration Date:    -- (mm/yy)

By submitting this form, you are representing that the credit card entered is valid; that you are authorized to use this credit card and, you are voluntarily giving CORE permission to charge this credit card for the amount indicated.

Thank You !

You have chosen to pay your membership fee by check or Money Order:

Please write down this information then click the CONTINUE button:

*Make check or money order payable to:*	CORE - Congress of Racial Equality
*Check Amount:*	$

*And mail it to:*	Congress of Racial Equality
	817 Broadway 3rd Floor
	New York, New York 10003

	Attn: Membership On-Line

Thank You !

Enter Total Amount

You chose to pledge a membership fee to CORE: Pledge: $

Please select one of the following options then click the CONTINUE button:

Mail the membership pledge to me at the address already provided above

Mail the membership pledge to the following address:

*Mr/Mrs:*	First Name: Last Name:
Company Name:
Mailing Address:	Suite/Floor:
City:	State: Zip Code:

Have someone contact me regarding my membership pledge at:

Telephone #: Best time to call is between: and (indicate AM or PM)

Review Choices

Please review and/or complete the choices you have made:

Enter Total

Enter Donation

Enter Fee

Membership Category:
Membership Fee:	$
Additional Donation:	$
Total Amount:	$
Method of Payment:
Pledge Option:

Thank You !

Enter any comments here then click the SUBMIT FORM button:

CORE enjoys a 501(C)3 status with the Internal Revenue Service.

Contributions to CORE are tax deductible to the extent allowed by law.

Information supplied on this form is confidential and will be transmitted over a secured line

directly to CORE's Membership Department.

* * * * * * * * *

* Amount to be Charged:	$
* Credit Card:
* Cardholder's Name:
* Credit Card Number:
* Expiration Date:	-- (mm/yy)