<p> Black Women Lawyers’ Association of Greater Chicago, Inc.</p><p>2015-2016 MEMBERSHIP APPLICATION</p><p>Dues are payable effective June 1 of each year. Please complete all applicable areas and send along with your check, payable to: BWLA Treasurer at: 321 S. Plymouth Ct., Suite 600 Chicago, Illinois 60604 P: 312.554.2088 F: 312.962.4345 Payments are also accepted via PayPal, ChasePay ([email protected]) and the BWLA website at www.bwla.org. MEMBERSHIP DUES & DONATIONS</p><p>FULL MEMBERSHIP $100.00 per year $______(Individual duly licensed to practice law and in good standing in the bar.)</p><p>Bar Admission State ______and Attorney Registration Number______</p><p>NEW ADMITTEE (FULL MEMBERSHIP) FREE (Free membership for first year after admittance to the Bar) $ FREE</p><p>Bar Admission State ______Year ______</p><p>ASSOCIATE MEMBERSHIP $100.00 per year $______(Individual not licensed to practice law, but completed the study of law and received a JD or equivalent.)</p><p>PARALEGAL MEMBERSHIP $100.00 per year $______(Individual working in a legal setting as a paralegal)</p><p>STUDENT MEMBERSHIP $10.00 per year $______(Individual currently registered for and engaged in the study of law at any college, university or school of law.)</p><p>Law School: ______Year ______</p><p>BWLA Scholarship Fund Donation (Optional: Tax-exempt donation supports annual scholarship awards to law students) $______</p><p>BWLA Operating Expense Donation (Optional: Supports funding for community service events and other BWLA programming) $______</p><p>BWLA Member Hardship Donation (Optional: Supports BWLA membership for unemployed/underemployed black woman lawyer) $______NAME______</p><p>PREFERRED MAILING ADDRESS______CITY/STATE/ZIP______</p><p>PHONE______FAX______E-MAIL* ______*Email is our preferred method of contact</p><p>FIRM OR BUSINESS NAME______</p><p>PRIMARY PRACTICE AREA(S) ______</p><p>COMMITTEE PARTICIPATION: BWLA operates through committees. Please select the committee(s) on which you are interested in serving. COMMITTEES:  Progressives (age > 40)  Community Service  Mentoring  Government Service  Roundtable  Governance/By-Laws  Law Student Outreach  Advocacy & Legislative  Solo/Small Firm  Judicial Evaluations  Fundraising/Sustainability  Awards & Nominations  Spring Fundraiser  Membership  Website/Social Media  Corporate Counsel  Young Lawyers (< 10 yrs)</p><p>☐ CONSENT AND RELEASE: By checking this box, the undersigned hereby grants permission to the Black Women Lawyers’ Association of Greater Chicago, Inc. and its affiliates and agents (collectively, “BWLA”) to take, use, modify, reproduce or publish his/her appearance or likeness by means of photographic equipment, photographs or other techniques and/or media (including but not limited to brochures, calendars and other promotional materials), and to use his/her name (at BWLA’s option) in any printed matter which contains his/her appearance or likeness. The undersigned hereby disclaims any and all copyrights in such works. </p><p>Signature______Date______Visit us: www.bwla.org Contact us: [email protected] (general info), [email protected] (membership)</p><p>321 S. Plymouth Ct., Suite 600Chicago, Illinois 60604 Phone: 312.554.2088 Fax: 312.962.4345</p>