PO Box 30 | Supply, North Carolina 28462
910.755.7473 | www.brunswickcc.edu/foundation
2019-2020 Membership Form
Please return this completed form with your payment to:
BCC Foundation
Attn: MPLB
PO Box 30
Supply, NC 28462
In support of Men in Philanthropy & Leadership of Brunswick, I pledge and agree to a payment
of $ _______________________ for 2019-2020 MPLB Membership.
Minimum amount of $100.00. Checks may be made payable to: Brunswick Community College Foundation
Please call 910-755-7473 and speak to Kathy Lukacz to pay with credit card.
_________________________________________ _____________
Signature Date
Member Information
Name ________________________________________________________________________
Address _______________________________________________________________________
City _________________ State ________________________ Zip ______________________
Telephone __________________________ E-mail ____________________________________
Other Organizational Affiliations/Roles? _____________________________________________
______________________________________________________________________________
______________________________________________________________________________
Interests (Check all that apply)
__ Middle School Mentoring
__ Scholarship Review
__ Student Ambassador Mentors
__ Member Recruitment
__ Nursing Mentorship
__ Speakers Bureau
__ I prefer to support MPLB financially
Thank you for supporting Men in Philanthropy & Leadership of Brunswick!
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