John D. O'Bryant National Think Tank for Black Professionals in Higher Education 
on Predominantly White Campuses

Membership Application

 

Title: Dr.   Mr.   Mrs.   Ms.   Rev.

Name:

Position Title:

Institution:

Mailing Address:

City:      State:      Zip Code:

Daytime Phone:    Fax:

E-mail Address:

T-shirt Size:  

 

Demographic Information

Sex:   Male   Female 

Race: 
African American
Asian/Pacific Islander
African American
Asian/Pacific Islander
Caucasian
Hispanic
Native American
other:  

Work Setting:
 4-year private
4-year public
2-year private
2-year public
community college
other:  

Highest Degree (of your institution):
 Associate
Bachelors
Masters
Doctorate

Size of Institution (total enrollment):
 more than 20,000
between 10,000 and 20,000
between 2,000 and 10,000
less than 2,000

Years in Field:
 0-5
6-10
11-15
16-20
21-25
26 or more

Functional Area:

Committee(s) you are interested in serving on:

Administrative Affairs

Business and Finance

Constitution and Bylaws

Editorial Publications

Faculty Affairs

Human Resources

Research and Professional Development

Membership

Public Relations

Speakers Bureau

Strategic Planning

Student Research and Development

Summit Coordinating


Membership Category (please select only one)

$50 Professional (any person whose responsibilities relate to student and human development in Higher Education).

$35 Student (any person currently engaged in graduate studies who is not employed full-time).


Payment Method (payable to JDOTT)

Check        Money Order


Please complete and return this form, along with payment to:
JDOTT
University of Cincinnati
Contract Station
P.O. Box 219097
Cincinnati, OH  45221-1097

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