LSU BFSC Membership Form

Black Faculty and Staff Caucus

JOIN the Black Faculty and Staff Caucus at Louisiana State University!

Membership Type*

New Renew

Name*

First Name

Last Name

Preferred Pronouns

LSU Identification Number (89) *

89XXXXXXX

Employee Classification *

Campus*

Campus Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Department

Title

Phone*

(XXX) XXX-XXXX

Email*

Confirm Email Address *

Membership Options*

GROUP 100 Traditional Membership

GROUP 100 Payment / Deduction Options *

One-time payroll deduction of $100 One-time Venmo payment (@LSU-BFSC) Bi-monthly payroll deduction payments across 12-month period (classified employees) Monthly payroll deduction payments across 12-month period (professional/unclassified employees) Monthly payroll deduction payments across 9-month period (faculty)

GROUP 100 Payment / Deduction Options*

One-time Venmo payment (@LSU-BFSC)

Other:

LSU Alumni Association Employees Only

GROUP 100 Payment / Deduction Options*

One-time Venmo payment (@LSU-BFSC)

Other:

LSU Foundation Employees Only

Traditional Membership Options*

$10 Annual Membership for Classified Staff $20 Annual Membership for Professional Staff $30 Annual Membership for Faculty $40 Annual Membership for Senior/Executive Leadership (AVC, Dean, VC/VP, etc..)

Traditional Membership Payment / Deduction Options *

One-time payroll deduction One-time Venmo payment (@LSU-BFSC)

Traditional Membership Payment / Deduction Options *

One-time Venmo payment (@LSU-BFSC)

Other:

LSU Foundation Employees Only

Traditional Membership Payment / Deduction Options*

One-time Venmo payment (@LSU-BFSC)

Other:

LSU Alumni Association Employees Only

Donation (Contribution of any amount above annual membership)

Donations help the caucus sponsor educational, cultural, and social programs central to our mission. No amount is too small!

Total Amount (Membership Option + Donation)*

I authorize that all information provided on this form, including all personal and employment data, may be shared with the LSU Black Faculty and Staff Caucus to process membership fees and donations. This data will be securely retained indefinitely. To learn more about privacy at LSU, please see the LSU Privacy Statement.

Data Consent*

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Signature*

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Date/Time*

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