RBPP LOU Application

Revolutionary Black Panther Party

The Select Few: The dignified Screening Application
Name

PrefixFirst NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
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?
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?
If yes, please specify the charges and current status.
Do you have any outstanding warrants?
If yes, which charges do you have outstanding warrants for?
Are you currently on probation?
If yes, which charges are you currently on probation for?
Have you ever been convicted of a sexual crime?
If yes, please explain what the charge is and the current status.
Are you a registered sex offender?
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?
If yes, please explain
Are you religious?
Please select how you classify your beliefs.
Are you with, or affiliated with any other Black groups or Black organizations?
Are you affiliated with any other Black groups or organizations?
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?
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?
Are you trained in firearms training?
Are you officially trained in handling and using firearms?
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?
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.
Emergency Contact Information

Please provide two (2) emergency contacts and their current phone number.
Emergency Contact #1

First NameLast Name
Phone Number
Please enter a valid phone number for your emergency contact person.Format: (000) 000-0000.
Emergency Contact #2

First NameLast Name
Phone Number
Please enter a valid phone number for your emergency contact person.Format: (000) 000-0000.
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?
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

MonthDayYear
Date
Please upload a picture of you official Driver License or government issued ID.

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Revolutionary Black Panther Party

Emergency Contact Information