Please Print Legibly

Date:_______________
Name:____________________________
Address:___________________________________________________________________________________________
________________________________________________________
City: __________________

State:_______________

Zip Code: ______________

Contact Number: (______) _________-__________

Preferred Email: ______________________________________________________________
NSHE#: _______________________________ Classification: ___________________________
Major: __________________ Minor: __________________

Shirt Size: SM M L XL XXL

Please list any other organization you belong to (on campus/community):

__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________
I, do hereby, certify that all of the above information is true. I understand that submitting fraudulent information will affect my
membership into the Black Student Organization. Lastly, I understand that my NSHE number will not be used for anything
other than to verify my student status; anything else requires my written consent

Signature: ______________________________________________________

For Official use only please do not write below this line
Dues Collected:

Yes

No

Membership Card Issued: Yes

No

Date:_________________________
Initial: ___________________________
Fall: ________________________

Spring:_________________________