Membership Application

for the

USDA Coalition of Minority Employees

Name:________________________________________________________________________

Department/Agency:____________________________________________________________

Title:_________________________________________________________________________

Member Status: New  Member__________________ Renewal Member____________________

Active__________________________________Non Active_____________________________

Chapter Location_________________________Member#( if active)______________________

Renewal Date (if active)_______________Pledge Amount______________________________

Payment Method: Payroll Deduction____________Check______Money Order_____________

Contact Information:

Office Address:_________________________________________________________________

Office Telephone:(____)________________E-mail Address_____________________________

Home Address:_________________________________________________________________

City__________________________State________________Zip Code____________________

Home Phone: (____)_____________________________

Send publications and information to:   Home Address____   or   Work Address____

 Our website address is www.agcoalition.org. or you can  E-mail us at @agcoalition.org.

Membership dues are $26.00 per year. Make checks payable to "Coalition" and mail to:

P.O. Box  23510

Washington, D.C. 20026

The “Coalition” has automatic payroll deduction. 

Please contact Linda Epstein  in room 1566-S  or at 202-720-2212