Mississippi Workers Center for Human Rights

213 Main Street ~ Post Office Box 1223 ~ Greenville, MS 38702-1223

Phone: 662-334-1122 ~ Fax: 662-334-1274

Membership Form

Name ________________________________________________________________________________________

Address ______________________________________________________________________________________

Phone Numbers (H) _________________________________ (W) _______________________________________

Employed ______ Unemployed _________ How long ________________________________________________

Name of Workplace ____________________________________________________________________________

Address of Workplace ___________________________________________________________________________

County ________________________ Job Title _______________________________________________________

Membership Fee: $10.00

Date ______________________ Signature ___________________________________________