3450 Mount Vernon Drive, Los Angeles, CA 90008

MEMBERSHIP APPLICATION

Thank you for being an active part of THE MOVEMENT! Membership dues are due annually from the month of your initial
application. If you have any questions, please contact us at membership@laulyp.com

New Renewal Update Personal Information Membership Type: $100 General $25 Undergraduate (proof of current registration is required)
Status:

____________________________________________
Full Name Mailing Address ____________________________ City _________ State

___________________
Date of Birth

_______________ Zip Code

( ) Phone Number

________________________________________________ E-mail Address (By providing your email address above, you authorize
the Los Angeles Urban League and LAULYP to contact you electronically.)

Education (Check highest level of completion)

________________________________________________ Place of Employment ________________________________________________ Title/Occupation ________________________________________________ College/University ________________________________________________ Major(s)/Degree(s)

High School Associate Trade Bachelor Degree Graduate Degree/Higher

List any other organization affiliations and any leadership positions held. List any talents, training, or certifications you hold that would be an asset to the LAULYP. How did you learn about LAULYP?

Website Event & Location: _______________________________ Member: ________________________

Reason(s) for joining LAULYP? What committees are you interested in? (Check all that apply)

Community Service/ Education & Scholarship Marketing/E-Marketing/PR Membership Major Events Professional Development Policy & Procedure Civic Engagement & Political Awareness
The following information below will be kept confidential and is used to summarize demographic information of our membership to solicit sponsorship.

Fund Development

$25-50K $50-75K $75-100K $100-200K $200K+ Marital Status: Single Married Divorced Widowed Separated Ethnic Background: Black White Hispanic Asian/Pacific Islander Native American
Salary Range: Other_________________________________________________________________________ Are you a registered voter?

OFFICE USE ONLY

Yes No

Date: ________________ Amount Paid: _________ Payment type: ________ (Check No.__________) Notes: _______________
Application Version January 18, 2011