Membership Application

Membership Application
100 Black Men of Macon Middle Georgia

P.O. Box 26152 Macon, Georgia 31221

Donnie Fletcher, Committee Chair

Committee Members:

Willie Billingslea - Steve Williams - Joe Lawson - Garrett Williams
Required

You must have a reference from a member in good standing

Please submit a copy of your Bio and Resume with application

NOTE: All Applications are reviewed by the membership committee
First *
Middle
Last *
Date of Birth *

Month Day Year
Date
Telephone *
Street *
City *
State *
Zip Code *
Email *
example@example.com
Please complete this section if you are a Business Owner:
Business Name
Street Address
Business Phone
City
State
Zip Code
Place of Birth
*
City
*
State
*
County
Community Involvement *
Tell us about your community involvement
Skills/Hobbies *
Tell us about any skills or hobbies you have.
Employment History
Current Employer Information *
Name:
*
Position
*
Dates of Employment
*
Address
*
City
*
State
*
Zip Code
Past Employer Information *
Name:
Past Employer Information *
Name:
*
Position
*
Position
*
Dates of Employment
*
Dates of Employment
*
Address
*
Address
*
City
*
City
*
State
*
State
*
Zip Code
*
Zip Code
Education/ Training
High School *
Name of High School:
*
Diploma/Degree/Certification
*
Location
College
Name of Institution:
Diploma/Degree/Certification
Location
Other Education
Name of Institution:
Diploma/Degree/Certification
Location
Other Education
Name of Institution:
Diploma/Degree/Certification
Location
Dues Payment - *Note: A 3.75% service charge will be applied for credit card payments. *

Quarterly - $250.00 Semi-Annually - $500.00 Annually- $1000.00
Signature *

Clear
Date *

Month Day Year
Georgia Bureau of Investigation

Georgia Crime Information Center (GCIC)

Consent Form

I hereby authorize 100 Balck Men Macon-Middle Georgia to recieve and Georgia criminal history record information pertaining to me which may be in the files of any state or local justice agency in Georgia.
Name *

First Name Middle Name Last Name
Address *

Street Address

City State / Province

Postal / Zip Code
Sex *
Race *
Social *
Last four only
By signing this form, I acknowledge that I have been informed of the Non-Criminal Justice Applicant's Privacy Rights and the Privact Act Statement (Title 28 United States Code § 534) and Affirm that I have retained a copy (attachements A and B) for my records.
Signature *

Clear
Date *

Month Day Year
Special employment provisions (check if applicable): Employment with mentally disabled (Purpose Code “M”) Employment with elder care (Purpose code “N”) Employment with children (Purpose code “W”)One of the following must be checked:

This authorization is valid for 90 / 180 / (circle or enter) days from date of signature. Type I _________________________________________ give consent to the above named to perform periodic criminal background checks for the duration of my licensure with this state.
Name

First Name Middle Name Last Name
Member Reference *

pdf, doc, docx
Cancel of
Bio *

pdf, doc, docx
Cancel of
Resume

pdf, doc, docx
Cancel of
Should be Empty: