Your Name (First, Middle Initial, Last, Suffix)
Address
City/State/Zip
Home Phone
Cell Phone
Email
Date of Birth
Name of Sponsoring Member (First and Last)
New Member? YesNo
Reinstated Member? YesNo
Transferring Member? YesNo
Current Employer
Work Phone
Fax
Position
How Long?
Name (First, Middle Initial, Last, Suffix)
Organization #1
Active? YesNo
Organization #2
Organization #3
Do you hold office in 1, 2 or 3? If so, which organization and which position?
Reference 1 Name
Phone
Reference 2 Name
Reference 3 Name
How did you hear about 100 Black Men of Maryland, and why are you interested in becoming a member?
Please tell us of your previous experience in working with youth, especially of the age range between 8 and 18.
What special skills, talents, abilities or knowledge do you bring to the organization? For example, fundraising, grant writing, computer skills, musical abilities...
Because our programs involve working directly with youth, a criminal background check is mandatory of all applicants and must remain current throughout the duration of membership, if accepted. To my knowledge, there are no current of past activities in my background that would disqualify my membership. YesNo
Which 3 committees you would like to serve on, in the event we need you on more than one? Please prioritize them by first choice to 3rd choice (choose 3). Committees: Mentoring, Education, Health & Wellness, Economic Empowerment, Fundraising, Membership, Events, Media Public Relations, Strategic Planning, Technology, Finance, Scholarship
Finally, if you know others whom you would strongly recommend join you in membership at 100 Black Men of Maryland, we hope you would get his permission to provide his name and contact information so our membership Chair would send him an invitation to join us. You may provide the name below after consulting him.
Thank you for your application to join 100 Black Men of Maryland. Please check your application for completeness and when you are satisfied, submit this form and mail your $100 application fee to: Membership Director, 100 Black Men of Maryland, Inc., 4413 Liberty Heights Avenue, Gwynn Oak, Maryland, 21207-7557. Please note your full name and that you submitted your membership application online.
Or you may click here to pay your application fee via PayPal or with a credit card. Should you choose this option, please note your full name and that you submitted your membership application online in the "Special Instructions" section. APPLICATION FEES ARE NON-REFUNDABLE.
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