University of South Carolina
Black Faculty Caucus
Membership Form
Pursuant to USC Black Faculty Caucus approving the membership dues for this Academic Year, please fill
out the following information:
Name (Print Last & First)
Department or Unit:
Title/Position:
Are you classified as a (check all
that apply):
TenureTrack
Faculty
Adjunct
Faculty
Visiting
Faculty
Research
Professor/
Scientist
Office Address:
Preferred Telephone:
Preferred Email Address:
Areas of teaching and/or
research expertise?
Please name a committee or
activity in which you are
interested in participating:
Status of your membership dues
(check one):
Signature and Date:
Signature of BFC Executive Board
member:
Have Paid:
Intend to Pay:
Other
(please
indicate
below)