Membership application

The information on this form is strictly confidential and will not be shared with any other entities. This will only be used for internal processing by our applications manager as a way to prescreen applicant eligibility. Upon completion of this form, a member will reach out to you with next steps. All questions must be answered to be considered for membership.

We understand some of the questions are very personal. We take membership very seriously, as we work directly in the community and need to be able to guarantee the safety of the people. All application information is only seen by one person, it is not shared among any of the ministry or general members. After acceptance or rejection, all info besides your name, email, and number if accepted, can be deleted upon request.

Email

example@example.com

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long have you lived in the Dayton area?

If you are applying as an out of city resident put Na-out of city

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

State Drivers License/ID Number and State Issued

Do you have any physical limitations? If yes please explain.

Have you been diagnosed with any mental illnesses? If yes please explain

Do you have any pending criminal charges against you? If yes please explain

Why are you interested in becoming a Black Panther?

Do you understand that this organization is based in Marxist Leninist ideology?

Social media handles?

Instagram, Facebook, Twitter etc

Best way to reach you?

Text, call or email

Dayton Black Panther Party Membership Application