If you have read our mission statement and wish to become a member, then

PLEASE PRINT OUT AND MAIL TO:

THE BATON ROUGE COUNCIL ON HUMAN RELATIONS

254 NELSON DRIVE, BATON ROUGE, LA 70808

MEMBERSHIP APPLICATION

Being in agreement with the principles of the Baton Rouge Council on Human Relations as set forth in its Statement of Purposes, I submit my applications for membership in the Council and enclose payment as follows:

( ) Single membership������..$15.00

( ) Family membership������.$20.00

( ) Student/low income membership.�$1.00

Date

_____________________________________________________________________

Name

_____________________________________________________________________

Street Address or Box Number

_____________________________________________________________________

City�������������������������� �������������������������������������������������State���������� ������������������������Zip

________________________________________

telephone

________________________________________

email

_______________________________________

Signature