National Coalition of 100 Black Women, Chattanooga Chapter, Inc.

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1 NCBW Chattanooga Chapter, Inc. Application 1 National Coalition of 100 Black Women, Chattanooga Chapter, Inc. MISSION STATEMENT The National Coalition of 100 Black Women, Chattanooga Chapter Inc. is an organization that advocates an enhanced quality of life for individuals and families of color by facilitating programs that address their needs and unites the public and private sector of Chattanooga to ensure progress of African American women. While establishing a sisterly bond, these programs foster leadership, educational opportunities, economic partnerships, women s health issues and political strength. ****************************************************************************** All sections of the application must be completed including your Voter Registration number and endorsements by two active members. Failure to comply will void your submission. (Type or print legibly) Personal Information MEMBERSHIP APPLICATION Name: Last First Middle Preferred Name Home Address: City: State: Zip Code: Home Telephone: _ Home Fax: Home Date of Birth: Spouse: Last First Middle Preferred Name Employment Information Employer: Address: City: State: Zip Code: Occupation/Title: Telephone: Fax: Church Affiliation: _ Voter Registration Number: _ Precinct Number: Have you been convicted of a felony within the past ten (10) years? Yes No

2 NCBW Chattanooga Chapter, Inc. Application 2 Educational Background Complete for all institutions attended High School/GED _ Name Location Date Graduated Diploma/Other Undergraduate/Technical School/Other _ Name Location Date Graduated Degree/Diploma Advance Degree(s) _ Name Location Date Graduated Degree/Diploma Name Location Date Graduated Degree/Diploma Professional Background, Recognitions and Affiliations Which of the following categories best describe your current position? Circle all that apply. Business & Industry Education Entrepreneur Finance Government Health Labor Law Media/Public Relations Nonprofit Religion Social Services Technology/Computers Other (specify) Briefly describe your employment responsibilities:

3 NCBW Chattanooga Chapter, Inc. Application 3 Does your employer support employees who are engaged in community and civic activities and if so, explain how? List professional awards, honors and achievements you have received that you consider significant. List current and/or past professional affiliations you have had. Do not include civic organizations, public office or political activities. Organization and Position Held Affiliation Dates

4 NCBW Chattanooga Chapter, Inc. Application 4 Community Service Participation: During the past three years, describe your involvement in two (2) community activities (civic, religious, political, government or social. Do not include professional activities). Indicate the name of the organization, your assignment/position, and describe your responsibilities and accomplishments for each. Organization1: Name What did you do? Assignment/Position Organization2: Name What did you do? Assignment/Position List current and/or past community and civic affiliations: Organization Position Held Affiliation Dates Program Participation, Contributions and Commitment What NCBW Chattanooga Chapter events have you attended and/or supported? When? Why do you want to join NCBW Chattanooga Chapter?

5 NCBW Chattanooga Chapter, Inc. Application 5 What value will you add to NCBW Chattanooga Chapter that will help promote the local and national organization s mission? Indicate the following area(s) that best describe your area of expertise. Circle all that apply. Advocacy Fundraising Grant Writing Health Law Mentoring National/Local Legislative Affairs Public Relations/Media Technology/Computers/Website Management Women s Rights Issues Other (specify) Orientation for new members may consist of several sessions and is mandatory. Will you commit to attending all sessions? Yes No. Membership requirements and responsibilities as an active member include participation in NCBW Chattanooga Chapter activities, attendance at bi-monthly membership meetings, and support of NCBW Chattanooga Chapter fundraising activities. Questions concerning membership requirements should be directed to NCBW Chattanooga Chapter sponsoring member.

6 NCBW Chattanooga Chapter, Inc. Application 6 Applicant s Statements In order to be accepted for membership in the National Coalition of 100 Black Women, Inc., Chattanooga Chapter (NCBW), I understand that I: Must commit and be an active member willing to devote time to the interest, goals and objectives of NCBW; Must be a U.S. citizen, registered voter, and of sound moral character; Am aware of the many problems facing women today both in the home and in the business community and that I am willing to be an advocate for the empowerment of women and use my experience, expertise and influence to improve the status of all women; Must have demonstrated active or past participation in community service (i.e., social, cultural, educational, political or religious); Must be sponsored by two (2) financial and active members; Have resided in Hamilton County or in a county that is within a 30 mile radius of Hamilton County corporate limits one year prior to my application for membership. Applicant s Signature Date Sponsoring Member s Signature Date Sponsoring Member s Signature Date

7 NCBW Chattanooga Chapter, Inc. Application 7 Application Procedures 1. Applications may be obtained from any member of the National Coalition of 100 Black Women, Inc., Chattanooga Chapter. 2. Application must be completed and postmarked no later than April 10, 2014 with required signatures, a black and white photo, two sponsoring members statements, and membership fee of $ Failure to include any of these items will result in application being denied. 3. Applicant must be available for a scheduled interview during the month of April with the Membership Committee. 4. With the exception of two sponsoring members statements, please do not add additional sheets to the application. 5. Applications that meet the membership criteria will be presented to the general membership for voting at the May meeting. All applicants will be notified of their acceptance or non-acceptance. Successful applicants must remit an installation fee of $50 within one (1) week of notification of membership acceptance. The $500 membership fee will be refunded within 30 days of the May meeting to applicants whose memberships were not approved. 6. Application, black and white photo and $ membership fee made payable to NCBW Chattanooga Chapter must be mailed to: National Coalition of 100 Black Women, Chattanooga Chapter Inc. Attention: Membership Committee Post Office Box Chattanooga, TN Telephone: (423) Late applications or applications received in envelopes that have not been postmarked by the required April 10, 2014 date will not be processed. Do not hand-deliver or give application to any NCBW member to submit. Members Valerie Amaker Elizabeth Appling Ikeko Bass Katherine Bryant Tara M. Bryant Mary L. Cameron Colleen Canion Tara E. Daniels Ernestine Dobard-Hall Carolyn Y. Dozier Faith R. Edwards Debbie Jones-Ellis Rep. JoAnne H. Favors* Deborah A. Flagg Tina Fielder-Gibson Tina Dobard-Hall Ruthie Hereford Ingrid K. Jackson Vanessa A. Jackson Beverly P. Johnson, MRP* Carolyn G. Jones, RHIA * Doris. P. Jones Sheila D. Keith* Theresa Vickie Kellum Jacqueline Lyons* Patricia D. Mason* Amanda Vickie Mathis Laverne McGee Beverly A. McKeldin Renee B. Merrell Carol K. O Neal, CMC* Christy E. Rashed Barbara Scott Rev. Dr. Eva M. Settles* Donna H. Stone Dr. Elaine Swafford Juliette R. Thornton* Bernadine Turner* Juanita Dawson Ulmer Patricia Underwood- Williams, MA* Charlesetta Woodward- Thompson* Gloria S. McKeldin, President *Denotes charter member

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