Membership Application Form
National HBCU Health Care Services Research Network
To join the HBCU Health Care Services Research Network please print and mail the following document.
I want to become a member. Please check:
___ Voting Membership - $100 per year ___ Student Membership - $25 per year*
___ Non-voting Membership - $50 per year ___ Retired Senior Membership - $50 per year**
_________________________________________________________________________________
Name:_____________________________________________________________________________
Position/Title:_______________________________________________________________________
Organization:________________________________________________________________________
Business Adress:_____________________________________________________________________
City/State/Zip:_______________________________________________________________________
Business Phone:_____________________ Fax:_______________________
E-mail Address:______________________________________________________________________
Home Address:______________________________________________________________________
City/State/Zip:___________________________________________ Home Phone:_______________
Please check one or two sections below that describe your area of research interest
__01 Administration/Management __07 Nutrition __13 Rehabilitation
__02 Education __08 Medicine/Dentistry __14 Religion
__03 Mental Health/Counseling __09 Communication/media __15 Science/Technology
__04 Planning/Developement __10 Public Policy __16 Recreation/Arts
__05 Business/Finance __11 Nursing __17 Law
__06 Physical/Occupational/Speech Therapy __12 Service Provider __18 Other ___________________
A check for$______ is inclosed (Payable to the National HBCU Health research Service Network). Please bill my organization (Purchase order#). Return form with your payment to:
National HBCU Health Research Network
Old Science Center Room 308
1200 North Dupont Highway
Dover, DE 19901.
*MUST FURNISH PROOF OF FULL-TIME STUDENT STATUS **SIXTY OR OLDER