Any individual who identifies her or himself as Black
(African or African-descended), and agrees with the
BRC Principles of Unity, is eligible for membership in
the Black Radical Congress.  Please print this form,
fill it in (type or print clearly), and return to the
address below.


Name ____________________________________________

Address _________________________________________

City _______________________ State ______ Zip ______ 

Phones (day) _______________ (evening) _____________

Fax _____________________________

Email/WWW ___________________________

Organizing Committee (if applicable) _________________


Please provide the following information

1. Age ____

2. Occupation ____________________________________

3. Which BRC Caucus(es) would you like to join?

   ____ Working/Labor   ____ Youth   _____ Feminist

   ____ Lesbian/Gay     ____ International

4. What other political groups do you belong to?

5. Please indicate the arena(s) of struggle/issues    
   which you want to work on:

   National areas of work
   ( ) Anti-Police State
        [ ] Mumia Abu-Jamal
        [ ] Assata Shakur
        [ ] Other ____________________________
   ( ) Economic Justice
   ( ) Public Education
   ( ) Reparations

   Other areas:
   ( ) Health Care ( ) Electoral Reform
   ( ) Violence    ( ) Housing/Gentrification
   ( ) Welfare     ( ) Affirmative Action
   ( ) Culture     ( ) Labor Organizing
   ( ) Drugs

6. Please list some of your skills, talents, or 
   resources that could help build the BRC in this 
   period:




7. Please check the appropriate amount for your Yearly
   Dues:

   ___ $1.00           (unemployed)
   ___ $10.00          (students, seniors, low income)
   ___ $25.00          (general membership)
   ___ $50.00 and over (supporter membership)


Signature __________________________ Date __________


Please mail with your check or money order for the
amount specified above to the National Office:

Black Radical Congress
National Office
Columbia University Station
P.O. Box 250791
New York, NY 10025-1509
blackradicalcongress@email.com