1. MEMBERSHIP APPLICATION
*For internal Use Only
Black Young
Black Young Professionals
Urban League of Rochester, N.Y., Inc.
Personal
 Miss  Ms.  Mrs.  Mr.  Dr.  Other
Name _____________________________________________________ Birth Date_________________
Address _____________________________________________________________________________
City/State/Zip________________________________________ Mobile Phone ___________________
Professional
Business Name________________________________ Title ________________ ___________________
Business Phone____________________________ Email_______________________________________
Educational
School _________________________________________________ Degree ______________________
Other License/ Certification/ Other________________________________________________________
Interest
 Membership Committee  Professional Development Committee
 Community Service Committee
Other
Please list any other professional, civic, fraternal, or community organizations you are a part of as well as any
leadership positions you hold or have held.
___________________________________________________________________________________
___________________________________________________________________________________
Payment**
 $35 Annual Individual Membership  $200 Corporate Membership (Covers up to 6 Employees)
*Checks payable to Urban League of Rochester, NY Inc.
Mail completed forms to the attention of Jamie Rada at 265 North Clinton Ave., Rochester, N.Y. 14605
Card Type  Visa  MasterCard  American Express
Card Number ________________________________________Exp. ____ /____ AVS Code __________
Name on Card ________________________________________________________________________
Billing Address _______________________________________City/State/Zip _____________________
Signature _____________________________________________ Date ________________________
**Annual Membership Dues are Non-Refundable