Citizen Appointment Application

Citizen Appointment Application

Complete your details for an official appointment, then submit the form for review.
Applicant Information
Full Legal Name

First NameMiddle NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health, Background, and Experience
Health Status
Health Explanation
Ancestral Lineage
Desired Office/Position
Present Skills
Military Background (if any)
Ever Involved in a Legal Matter or Felony?
Disposition of Case / Statement of Expertise
Oath, Signature, and Dues
I, First Name*, hereby swear or Affirm to uphold the principles of the Shams 91 Government, to protect the rights of Black and Oppressed peoples, and to serve the Theocratic Democracy under the guidance of Dr. Shamsuddin A. Abdulhakim Bey.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dues Payment Amount
Should be Empty: