Revolutionary Black Panther Party
The Select Few: The dignified Screening Application
Name
Mr.
Mrs.
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
What city and state were you born in?
*
What current city and state do you currently reside?
*
What is your highest level of education? Area of study?
*
What is your current occupation?
*
Have you ever been arrested?
*
Yes
No
If yes, what were the charges? Please specify the current status of the charges. This does NOT disqualify you from being involved, but it gives us a transparent view of our members and how to best protect them while doing panther work.
Have you ever been convicted of a felony?
*
Yes
No
If yes, please specify the charges and current status.
Do you have any outstanding warrants?
*
Yes
No
If yes, which charges do you have outstanding warrants for?
Are you currently on probation?
*
Yes
No
If yes, which charges are you currently on probation for?
Have you ever been convicted of a sexual crime?
*
Yes
No
If yes, please explain what the charge is and the current status.
Are you a registered sex offender?
*
Yes
No
Are you a registered sex offender?
*
How do you feel about interracial dating & relations with white people? ( Answer honestly)
*
Are you prejudice against any race, gender, creed, religion or sexual orientation?
*
Yes
No
If yes, please explain
Are you religious?
Please select how you classify your beliefs.
*
Please Select
Religious
Spiritual
A little of both
Neither
Are you with, or affiliated with any other Black groups or Black organizations?
Are you affiliated with any other Black groups or organizations?
*
Yes
No
Please list the other groups or organizations that you are affiliated with and your duties/position.
Have you ever been in any other military service before? If yes, please provide your MOS & years served.
Have you ever served in any other military based service organization?
*
Yes
No
If yes, please provide your MOS and the years that you served.
Are you trained in self defense?
Are you officially trained in self defense techniques?
*
Yes
No
Are you trained in firearms training?
Are you officially trained in handling and using firearms?
*
Yes
No
Do you have any mental/medical conditions that will limit you from performing your military duties? If so, please send a copy of your medical summary of your limitations to, RBPP Admin @ Rpantherparty@gmail.com.
Do you have any mental/medical conditions that will limit you from performing military type duties?
*
Yes
No
If yes, please list those conditions. Also, submit a copy of your medical summary explaining your limitations to the RBPP ADMIN at Rpantherparty@gmail.com.
In the Revolutionary Black Panther Party, we have a monthly Membership Contribution. Please select the appropriate contribution amount that you will be making as a member.
*
$25.00 Employed Members
$10.00 Student Members
$0.00 Unemployed Members
Emergency Contact Information
Please provide two (2) emergency contacts and their current phone number.
Emergency Contact #1
First Name
Last Name
Phone Number
Please enter a valid phone number for your emergency contact person.
Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number for your emergency contact person.
Do you give the RBPP the right to do a background check, or screening if we have to for safety and security of yourself, the community, the RBPP and in order to complete your registration/enlistment and membership in the RBPP?
The RBPP will complete a background check and/or screening for the safety and security of yourself, the community, and the members of the RBPP organization. Do you give us permission to perform these checks to complete your registration/enlistment and membership in the RBPP?
Yes
No
RBPP is not a terrorist group and we do not practice any forms of terrorism, domestic terrorism, extremism or violent crimes of any kind. We will not tolerate any actions of this kind in or around the organization. If you understand and agree, please sign below.
Date
-
Month
-
Day
Year
Date
Please upload a picture of you official Driver License or government issued ID.
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