Membership Application Form

Your Details

Enter your current employer of business name.
Have you ever been convicted of a crime, other than any juvenile adjudication, which under the law which you were convicted was punishable by death or imprisonment in excess of 1 year, or that involved dishonesty or false statement regardless of the punishment? Note, a yes response does not automatically eliminate you from consideration for membership. If yes, please answer the next question.
if yes, state as to each conviction the specific crime and the date and place of conviction
A background check will be conducted as part of the application process. Do you agree to submit your social security number and date of birth to complete the background investigation if needed? Background investigations are normally submitted by the applicant and a copy of the results provided to the Membership Chair by the Applicant. You will be contacted by the Membership Chair if this information is needed.
Please include organization and chapter name(s).
Please provide character references including name, address, phone number, and relationship.
Tell us why you would like to be a member of 100 Black Men of Tampa Bay, Inc.
I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.