100 Black Men of Greater Washington, DC - New Member Interest Form

100 Black Men of Greater Washington, DC - New Member Interest Form
Interest Information: Please fill out this form to the best of your ability. If you have any question please email: Membership@100blackmendc.org
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Occupation
Title*
Company*
Number of years with employer
Do you know any current members of the 100 Black Men of Greater Washington, DC?*

YESNO
If so, who? What is your affiliation with them?
To volunteer or become a member with our organization, you must undergo a full background check. Is there anything about your background (this includes termination from a previous employer due to ethical reasons, legal matters, any abuse or harm to minors or adults, etc.) that would question your eligibility for membership with the 100 Black Men of America?*

YESNO
If yes to previous question, please explain.
Which of our Four Pillars within the Organization are you interested in participating with?*

MentoringEducationHealth & WellnessEconomic Empowerment
Provide any comments you would like to share with us.
Upon submission of this form the Membership Committee will be in contact with you to provide further instructions.
Should be Empty:

Occupation