P.O. Box 26152 Macon, Georgia 31221

Employment History

(List Current Employment First)
Current Employment
Previous Employer
Previous Employer
Education/Training
High School
College
Other Education
Other Education
Dues Payment

Annually - $1,000.00

*Note: A 4.75% service charge will be applied for credit card payments.

Consent Form

I hereby authorize 100 Black Men Macon Middle Georgia to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local justice agency in Georgia.
By signing this form, I acknowledge that I have been informed of the Non-Criminal Justice Applicant's Privacy Rights and the Privacy Act Statement (Title 28 United States Code 534) and affirm that I have retained a copy from the link provided below for my records.

https://www.govinfo.gov/content/pkg/USCODE-2011-title28/html/USCODE-2011-title28-partII-chap33-sec534.htm
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 days from date of signatureThis authorization is valid for 180 days from date of signature
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Bruce Riggins, President