Swim 21 Membership Application Template

Official use only:

Membership #: _____ Membership fee: $_____ Method of Payment: ______Receipt #: ______Black Business Student Association By: ______

Membership Application

Category of Membership (Circle One): New Renewal

Name: ______First Middle Initial Last

Date of Birth: __/__/_____ Student Id #______G.P.A.: ______

Class Level: ______Expected Graduation Date: _____/____ Semester Year

Major/Concentration: ______

Minor (if applicable): ______

Permanent/Mailing Address: Home Phone Number ______( ____)_____-______Mobile Phone Number ______( ____)_____-______

Email Address: ______

Please indicate how you learned about BBSA: ______

Are you interested in becoming actively involved? (please circle one below)  Yes, I would like to become actively involved, and have time to devote.  Yes, I would like to become actively involved, but have limited time to devote.  No, I do not wish to be actively involved, but do wish to take advantage of BBSA membership benefits. If you would like to be actively involved and have time to devote would you like to hold a position? (please circle one) Yes No If you answered yes, what position are you interested in? ______Please circle your shirt size: small medium large extra large 2xl* 3xl* *2xl & 3xl please add $3 to your membership fee

To become a member, please fill out this application completely and submit it with your membership fee and current resume to any BBSA Executive Officer or mail to:

Black Business Student Association c/o: Office of Student Life California State University, Dominguez Hills 1000 E. Victoria Street Carson, CA 90747

I would like to become a member of the Black Business Student Association (BBSA), and have filled out this application completely and accurately. I am submitting dues of $____ along with my application and agree that this information will held on my record for as long as I am a member.

Applicant Signature: ______Date: ___/___/_____

The BBSA Membership Fee is $30 per academic year or $20 per semester. This fee is non-refundable and will be used towards your BBSA shirt, business cards, and events.

“Creating Tomorrow’s Leaders, Today” The information contained within this document is privileged and private between Black Business Students Association (to be identified further as BBSA), the Applicant mentioned above, and Office of Student Life (OSL). Information contained within this document will not be given to any third party in any way or by any means whatsoever without the express written permission of the applicant, unless circumstances arise that it is a legal requirement to do so, and under these circumstances the applicant or the applicant’s parent or guardian if under the age of 18 yrs and OSL will be notified accordingly.