USDA
Membership Application for the USDA
Coalition of Minority Employees
Name:________________________________________________________________________
Department/Agency:____________________________________________________________
Title:_________________________________________________________________________
Member Status: New Member__________________ Renewal
Member____________________
Active__________________________________Non Active_____________________________
Chapter Location_________________________Member#( if
active)______________________
Renewal Date (if active)_______________Pledge
Amount______________________________
Payment Method: Payroll Deduction____________Check______Money
Order_____________
Contact
Information:
Office
Address:_________________________________________________________________
Office Telephone:(____)________________E-mail
Address_____________________________
Home
Address:_________________________________________________________________
City__________________________State________________Zip
Code____________________
Home Phone: (____)_____________________________
Send publications and information to: Home Address____ or Work
Address____
Our website address is www.agcoalition.org. or you can E-mail us at @agcoalition.org.
Membership dues are $52.00 per year. Make checks
payable to "Coalition"
The“Coalition” has automatic payroll deduction.
Please contact Ron Cotton at
rncott1@aol.com