100 Black Men of Eastern New York, Inc

ONE HUNDRED BLACK MEN OF EASTERN NEW YORK, INC.

Membership Application

Dear Applicant: Thank you for your interest in joining 100 Black Men of Eastern New York, Inc. Our Membership Committee requires that you furnish the information requested below. The Membership procedure. purpose, and other information regarding this organization is contained in our directory. A copy is available upon request.

In your membership for 100 Black Men of Eastern New York, Inc. members are requested to complete this form to provide the membership committee with updated and correct information for use in our Directory.

Date*

Date

Name*

First NameLast Name

Initial*

Preferred Salutation: Mr.: Address: Home:

Mr.

Dr.

Honorable

Commissioner

other

Address Home*

Zip*

Home Phone*

Format: (000) 000-0000.

Email*

example@example.com

Fax

Business Address *

Zip*

Business Phone*

Format: (000) 000-0000.

Email

example@example.com

Fax

Send Mail to: (check one): Home:

Home

Business

Personal

Date Of Birth *

Marital status*

Wife's First Name

Number of Children: Business Profession:

Number of Children*

Business Profession*

First Names*

Present Employer

Primary Business Profession

Primary Title/Function

Secondary Business/Profession

Secondary Title/Function: Sector: Business:Corp.:

Secondary Title/Function

Corp.

Partnership

Owner

Business/Professional Affiliations (List 2 most significant)

Education High School: College: College:

H.S Graduated*

College*

Major Field*

Year_*

Degrees*

College

Major Field

Year

Degrees

Other Specific Training Institutions

Field

Organizations or Affiliations: Civic. Service. Community. Board Memberships, or Offices held (List 3 most significant to

Honors, Awards, Special Achievements, Publications: (List 2 most significant)

Areas of interest for participation on Committees of 100 Black Men Inc. List 3 and identify by number in order of preference- You will be required to serve on at least one Committee.

1. Budget

2. Building Fund

3. Economic Development

4. Education

5. Dinner Dance

6. Health & Wellness

7. Mentoring

8. Newsletter

9. Newsletter

10. Organization of Black Investors

11. Political Action

12. Program

13. Publicity