100 Black Men of Milwaukee

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Membership Application

Email *

Full Name *

Mailing Address, City, State and Zip Code *

Present Employer *

Position/Title *

Type of Firm/Organization (for profit/nonprofit)

Business Address, City, State and Zip Code

Best Contact Number *

Do you possess a high school diploma/HSED/GED *

Yes

Name of High School *

Are you a college graduate?

Yes

Clear selection

If Yes, name of college/university?

Associate's or Bachelor's Degree Major?

Do you possess a graduate or professional degree?

Yes

Clear selection

If Yes, name of college/university?

Degree(s) earned

Are you an elected or appointed official?

Yes

Clear selection

If Yes, what is your office held?

What board memberships do you hold?

What organizational memberships do you hold?

How do you believe you can benefit 100 Black Men of Milwaukee? *

Please check the appropriate box regarding your referral for membership: *

Member referral

Self-referral for membership

Required

If referred by a current member, please provide his name.

All members of the 100 Black Men of Milwaukee, Inc. are required to pay a one-time $25.00 non-refundable application fee and $175 in dues, if accepted for membership. This fee will cover the cost of processing the application. I understand that my twenty-five dollar ($25.00) application fee is non-refundable and hereby give my consent to begin processing my application. You may use PayPal for payment of the application fee at milwaukee100@gmail.com. *

Checking this box acknowledges you have read and understand the information.

Required

I agree to and understand that in order for a thorough background check to be performed, I must provide 100 Black Men of Milwaukee, Inc. with proof of acceptance as a public/private school volunteer background check, volunteer for another legitimate organization which includes a background check for affiliation, to have been completed within the last calendar year from the date of this application. All information will be kept strictly confidential. I also understand any adverse information obtained will be considered in the decision whether to accept my membership application and /or limit the scope of my activities within the 100 Black Men of Milwaukee, Inc. I authorize any individual or entity to reveal to the 100 Black Men of Milwaukee, Inc. the results of this criminal background check. I release the 100 Black Men of Milwaukee, Inc. and any individual representative or entity from any and all claims, losses, liabilities, costs or expenses related to gathering and reporting this information. *

Checking this box acknowledges you have read and understand the information, and you give authorization and consent for release of information to the executive board of 100 Black Men of Milwaukee, Inc.

A copy of your responses will be emailed to the address you provided.

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