First Name

Last Name

Address

City State Zip

Phone (1) (2)

Fax

E-Mail

Organizing Committee (if applicable)

Please provide the following information

1. Date of Birth

2. Occupation

3. Which BRC Caucus(es) would you like to join?

Working/Labor Youth Feminist

Lesbian/Gay/Bisexual/Transgender International

4. What other political groups do you belong to?

5. Please indicate the arena(s) of struggle/issues which you want to work on:

National areas of work
Anti-Police State

Mumia Abu-Jamal
Assata Shakur
Other

6. Please list some of your skills, talents or resources that could help build the BRC.

7. Please check the appropriate amount for your Yearly Dues:

Please mail with your check or money order for the amount specified above to the National Office:

BRC National Office
P.O. Box 24795
St. Louis, MO 63115