State of Mississippi
Dues Year: ______________
Date:__________________
National Association of Colored Women’s Clubs, Inc.
1601 R Street, N. W. Washington, D. C. 20009-6420
Telephone #: 202.736.2044
Fax #: 202.726.0023
*If Possible Please Type All Information*
All forms must be completed in triplicate. All forms are to be sent to the elected State Financial Secretary, who will
maintain a copy for the state's records and send the original and one copy with all dues payments to the elected
State Treasurer, who will maintain one copy and send the original with all collected national dues to the office of the
National Association of Colored Women's, Inc. Any incomplete report will be returned to the elected State Treasurer
for proper completion.
Club Name:
______________________________ City:__________________
State:
MS
President:
_____________________ Phone Number:
Email:
No. of Members
New members: ____________
Amount Enclosed: $
Zip:
Please include current Name, Address, City/State/Zip Code and Telephone number, email address for each club member.
Please indicate new members by placing (*) next to their name. By not reporting all demographic information on each
member may result in members not receiving materials from the national office.
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